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Injury Prevention

Have you ever been stitched up?

Brian Mackenzie examines the causes and cures for stitch.

Typically, stitch is felt in the right upper abdomen, but may also occur on the left hand side, or may irradiate to upper or lower regions of the body. "Classic" stitch is more likely to occur to insufficiently trained people than well prepared athletes.

What causes Stitch?

Liver, spleen, stomach, small intestine and colon form a weight of several kilograms and are attached by ligaments to the diaphragm. The impact of every step forces the inner organs to move downwards. The diaphragm moves up and down as you breathe. Maximum stress occurs when your lungs are empty of air and you strike the ground with your foot. Stitch occurs most often on the right hand side and this may be due to the fact the liver, being the heaviest organ, is attached to the right side of the diaphragm. While the pain of a stitch is usually felt just below the ribs, some athletes report a stabbing sensation at the tip of the shoulder blade or even as high as the shoulder. Shoulder pain can convince some athletes that they are having a heart attack. A quick way to tell if it is stitch or a heart attack is to lie down on your back with your hips and legs elevated. If you have a stitch, the pain should be relieved almost immediately.

What to do about it

Fortunately, there are sensible steps to take both to prevent stitch from happening and to get rid of it once it occurs. If a stitch grips you during activity, one quick remedy is simply to change your breathing pattern. In athletes whose sports involve running, breathing and stitch are linked together because most athletes synchronise their breathing in line with their running rhythm and breathe in and out as the same leg strikes the ground.

Let us look at a specific example of this. In endurance runners, one of the most popular striding breathing linkages is 2:1. That simply means that two complete strides are taken for each breathing cycle (a breathing cycle consists of an inhalation and an exhalation). To calculate strides, you count only when the left or right foot hits the ground, not both. So, a 2:1 striding breathing linkage would mean that a runner might exhale when their right foot hits the ground and inhale the next time the right foot strikes terra firma (that is two strides and one breathing cycle). This pattern will be repeated over and over again, so the runner will exhale only when the right foot strikes the ground.

This pattern can lead to problems, because the diaphragm springs upward when we breathe out, increasing the tension on those flimsy ligaments. If we always breathe out when our right foot hits the ground, that means the jolting action of the foot will quickly lift the liver upward, but the massive organ will then fall back suddenly while the diaphragm is in its up position. That creates an immense pressure on the diaphragm, which can then go into the kind of painful spasm.

Should you experience stitch when running then initially change your breathing pattern so that the leg on the opposite side of the body from the stitch is the one that hits the ground whenever you breathe out. This simple change can frequently relieve the intense pain of stitching almost immediately.

Tim Quinlivan, a PE Teacher in Australia, has found the following method works well with his young athletes:

  • Slow your pace slightly
  • Grasp your side, where you feel the stitch, just under the bottom rib and half way across between the side and the belly button. Thumb to the rear and fingers to the front
  • Squeeze firmly and bend at the waist (45 to 90 degrees) while still running
  • After about 15 metres slowing straighten
  • The stitch should have gone

Four ways to prevent stitching

To keep stitch from striking in the first place, Jim Bledsoe recommends the use of the following four techniques:

1. Strengthen your diaphragm. As you make your diaphragm stronger and more flexible, you will reduce your risk of stitch, since the diaphragm will be able to both support and move with the liver's violent motions. To fortify your diaphragm, Noakes recommends "belly breathing", in which the abdominal area moves out dramatically with each inspiration and plunges in with each expiration, while the chest moves relatively little. To learn how to belly breathe, lie on your back on the floor and place a set of heavy books on your stomach. Breathe so that the books rise significantly as you breathe in and move downward as you breathe out. Repeat this belly-out, belly-in action when you are standing (without the heavy books, of course). Concentrate on repeating a similar abdominal action whenever you run during your sporting activity. As Noakes points out, this is not necessarily easy to learn; it can require many months for some athletes to develop good belly breathing.

2. Strengthen your abdominal muscles. It is not exactly clear why this helps, but athletes with strong abdominal muscles seem to have a much lower risk of stitch. Perhaps increased abdominal muscle tone helps to support internal organs and keeps them from jostling up and down quite as much. To strengthen your stomach muscles, lie down on your back with your hips and knees flexed and the soles of your feet on the floor, and then simply raise your head and upper chest repeatedly by about 30 degrees or more. Do not just flop back down after each raise; lower yourself gradually so that you will get nice, controlled, eccentric contractions of your abdominal muscles.

3. Food and drink. If you are stitch prone, do not take in any food or water for a couple of hours before you exercise. Eating or drinking shortly before exercising does increase the chances of stitch, possibly because the increased weight of a full stomach creates a stronger downward tug on the diaphragm as the stomach is jolted with each foot strike (cyclists usually do not have to worry about this rule, unless they are riding on a bumpy road). If you are going to be exercising continuously for more than an hour, you will want to take in some sports drink 10 minutes before the beginning of your exertion (to begin moving carbohydrate toward your muscles). In this case, you will have to rely on tips 1, 2, and 4 to keep you out of stitch trouble.

4. Relax. Stitches occur much more frequently in tense athletes. Before a competition or strenuous workout, spend some time taking deep breaths, and make sure your stomach is moving out expansively as you breathe in. Continue to breathe deeply until your diaphragm feels loose and free. Visualise yourself exercising with non tightened abdominal muscles and relaxed but forceful breathing. As your competition begins, monitor your abdominal area for tightness and concentrate on maintaining good belly breathing.

There are many other factors which increase the risk of stitch. Fast running is more likely to start a stitch because it features higher impact forces and more dramatic and quicker movements of the diaphragm. Running on rough, hard ground also raises the risk of stitch.

Stitch occurs more frequently on cool days than during warm weather. Stitch is also likely to show up when you are running downhill as it increases the jolting forces inside the abdominal cavity and also pushes your internal organs forward. It is recommended you exhale only when your left foot hits the ground whenever you run downhill.

Stitch can be prevented by following the simple rules outlined above. If a stitch does happen to strike you suddenly, change your exhalation foot immediately. If this does not help, lie down on your back with your hips and legs elevated.

My own experience as an endurance athlete was that by exhaling on the left foot strike provided me with a couple of decades of stitch free running.


Article Reference

This article first appeared in:

  • MACKENZIE, B. (2004) Have you ever been stitched up? Brian Mackenzie's Successful Coaching, (ISSN 1745-7513/ 10 / March), p. 1-2

Page Reference

If you quote information from this page in your work then the reference for this page is:

  • MACKENZIE, B. (2004) Have you ever been stitched up? [WWW] Available from: https://www.brianmac.co.uk/articles/scni10a1.htm [Accessed

About the Author

Brian Mackenzie is a British Athletics level 4 performance coach and a coach tutor/assessor. He has been coaching sprint, middle distance and combined event athletes for the past 30+ years and has 45+ years experience as an endurance athlete.

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