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When a stitch strikes


SUDDEN PAIN The pain of a stitch can stop you in your tracks.


Andrew O'Brien

A stitch in time saves nine. Everyone knows the old saying; a little bit of effort now will save more hassle later. But what about the other type of ‘stitch’, the one that can slow you down when you’re running, not saving any time at all?
If you have ever experienced one you know exactly what I’m talking about. A stitch, or side-stitch, is a pain that occurs somewhere in the abdomen when exercising, and thus has the imaginative, but correct name of Exercise-related Transient Abdominal Pain or ETAP.
Stitches are a bit of an enigma, there are numerous theories as to the root cause, but many of those have been debunked and others only go part of the way to explaining a cause. This is understandable – it’s hardly a life threatening condition, so research funding is more likely to be directed elsewhere.
That said, they can hurt a lot and severely impact on sports performance, particularly in endurance events. Those endurance events now attract more prize money than ever, so I would expect research funding into anything that effects performance to increase over time.

To make things more confusing, even what we do know is conflicting. Stitches are most common in running events, but can occur with any exercise, including swimming and horse riding.
They are relatively uncommon in children under ten, but most common in those under 20 years old, and tend to decrease with age.
Sports that require forward flexion of the trunk, such as cycling, tend to be relatively low risk, but there appears to be a link to thoracic kyphosis, or hunching of the upper back and they’re not uncommon amongst motorcyclists.
ETAP appears to be linked to pain at the tip of the shoulder during exercise, although it’s entirely possible to get one without the other.
One study found a higher incidence among female competitors at an ultramarathon, but the very small number of female competitors made it difficult to infer statistical significance.
Several studies have shown the type of fluid consumed before or during a session to be important, with hypertonic (high sugar) drinks more likely to provoke pain, followed by water, then isotonic drinks. It seems too much sugar is bad, but so is not enough.
The current best evidence suggests that ETAP is due to an irritation of the parietal peritoneum, which is the outer layer of the lining of the abdominal cavity. Irritation of the parietal peritoneum can produce sharp pain in the abdomen, especially at the side, and pain at the tip of the shoulder.
Irritation of the peritoneum can be brought on by movement, and relieved by stopping, much as with ETAP.
Children have a proportionally larger peritoneal surface area than that of adults which might explain the high prevalence of ETAP in the young. In addition to this, case studies have shown abdominal surgery to remove adhesions on the parietal peritoneum in competitive athletes to relieve symptoms of ETAP.

What to do
What can you do then, if you are prone to stitches? That’s a difficult question, because if we’re not certain what causes the pain, it’s hard to stop it from happening.
The main recommendations are to avoid eating or drinking large amounts in the two hours before exercise, and to stick to relatively small amounts during a session. It is advised to avoid hypertonic drinks, but also to train with what you will use in a race, to allow your gut to adapt.
There is some evidence that improving posture and core strength can reduce both the risk and severity of pain, and a suggestion that wearing a broad, supportive belt around the area could help.
And perhaps the most obvious, but also annoying, recommendation, is that slowing down will usually provide some relief.
A stitch in time saves nine, ‘they’ say. ‘They’ clearly never tried to teach clients how to avoid stitches at all.

Andrew O’Brien is a chartered physiotherapist and the owner of Wannarun Physiotherapy and Running Clinic at Westport Leisure Park. He can be contacted on 083 1593200 or at www.wannarun.ie.

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