By Joëlle Ramseier, physiotherapist at Kineo Seefeld
Suddenly there's a stitch in your side
You start out easy, and after a few minutes it tugs under your rib cage. The pain is sharp, often on the right, sometimes on the left, and forces you to walk. As soon as you stand still, it's gone again. Almost all runners know the side stitch, and it also occurs in swimming, horse riding and ball sports.
A side stitch is usually harmless. But if it comes on during almost every run, it takes the joy out of training and slows you down in races. The good news: there is quite a lot you can do to make it happen less often.
What is behind a side stitch
Medically, a side stitch is called "exercise-related transient abdominal pain". The exact cause has still not been conclusively established. Three explanations are mainly discussed:
- Irritation of the peritoneum: The peritoneum lines the abdominal cavity and is sensitive to pain. Friction or pull with every jolt could irritate it. This would explain why the pain can be pinpointed so well.
- Pull on the ligaments that hold the abdominal organs: The liver, stomach and spleen hang from ligaments that are connected to the diaphragm. The up and down of running pulls on them.
- Diaphragm and breathing: A shallow, hectic breathing rhythm and a full stomach could put extra strain on the area around the diaphragm.
One thing is certain: a side stitch occurs more often if you've eaten or drunk a lot shortly before training, especially sweet drinks and juices. Younger athletes are affected more often than older ones, and with more training it becomes less frequent for many people.
Typical situations
- A run straight after lunch or after a large breakfast
- Starting too fast without a warm-up, for example in a race
- Running downhill or tempo runs with a lot of jarring
- Big gulps from your bottle during the run
- A long break and then straight back into intense training
What you can do yourself
Acutely, when it stabs:
- Slow down clearly or walk briefly
- Breathe out deeply and slowly, possibly with pursed lips
- Press firmly on the painful spot with your fingers and lean your upper body slightly forward
- Change your breathing rhythm, for example breathe in for three steps and out for two
Prevention:
- No large meal two to three hours before an intense run; before easy runs, an hour's gap with light food is often enough
- In training, take small sips rather than large amounts, and test very sweet drinks before you use them in a race
- Warm up with ten minutes of easy running before the pace picks up
- Strengthen your trunk muscles, for example with plank and rotation exercises
When a side stitch is not a side stitch
A classic side stitch goes away within minutes at rest. Have your symptoms checked by a doctor if the pain continues after training, also occurs without exercise, comes with fever, nausea, vomiting or blood in the stool, or if you get stronger pain on every run.
Emergency: Pressure or pain in the chest, radiating into the arm, jaw or back, breathlessness, a racing heart or dizziness are not a side stitch. Stop training and get medical help immediately.
Sometimes the pain also comes from the thoracic spine or the rib joints. Then it often hurts when you rotate your upper body, breathe in deeply or press on a particular rib. That is a clear case for physiotherapy.
How we approach recurring side stitches
With frequent side stitches, we look at your training, breathing, trunk and spine together. It's important to properly rule out other causes.
1. Assessment: what we examine in your first session
- Detailed conversation: When in the run, which side, time since your last meal, drinks, pace and terrain
- Thoracic spine and ribs: Mobility in rotation and side bending, spring test on the ribs and tenderness at the rib margin
- Breathing pattern: Do you breathe mainly into the chest or also into the belly and flanks, and how does that change under load
- Trunk strength: Timed side plank and forearm plank, control during rotation exercises
- Running pattern: Upper body rotation, arm swing and cadence on the treadmill
2. Treatment in phases
- Weeks 1–2: reduce triggers. Adjust eating and drinking times, build in a warm-up, deliberately keep the pace low at the start.
- Weeks 1–6: trunk and breathing. Trunk training two to three times a week with side plank, Pallof press and dead bug, 3 sets each. Plus breathing exercises lying on your back and while walking.
- If the ribs or thoracic spine are involved: Mobilisation and exercises for rotation until turning and deep breathing in are free.
- From weeks 3–4: increase the load. Deliberately reintroduce tempo runs and downhill sections and observe when the stitch still occurs.
3. Kineo services we use
- Runners Physio: assessment and training planning specifically for runners
- Manual therapy for a restricted thoracic spine or irritated rib joints
- Medical training therapy for structured trunk training
- Currex 5D running analysis, if upper body rotation or arm swing stand out
- Digital home programme, so you do your trunk and breathing exercises regularly at home
Three trunk exercises for runners
- Side plank: On your forearm, body in a line, keep breathing calmly. 3 x 20–40 seconds per side.
- Pallof press: Stand side-on to a cable machine or resistance band, handle in front of your chest, stretch your arms forward without your upper body rotating with them. 3 x 10 per side.
- Dead bug: Lie on your back with arms and legs raised, alternately stretch one arm and the opposite leg, your lower back stays on the floor. Breathe out as you stretch. 3 x 8 per side.
From our practice
When runners come to us because of side stitches, the solution is often not a single measure. A combination usually helps: a bit more time since your last meal, a calmer start and regular trunk training. Not that rarely, we also find a stiff thoracic spine, and treating it relieves the symptoms further.
Running and physio under one roof in Seefeld
At Kineo Seefeld on Seefeldstrasse 83, stop Feldeggstrasse with trams 2 and 4, running is a focus. On the first floor we treat you with Runners Physio, and on the ground floor the Kineo Runners Lab analyses your running style with the Currex 5D running analysis.
Frequently asked questions
Is a side stitch dangerous?
As a rule, no. It goes away at rest after a few minutes. If the pain continues or chest pain, breathlessness or fever come with it, see a doctor.
Why do I mostly get a side stitch on the right?
This is often observed, but no definite reason is known. One explanation is the pull of the liver on the diaphragm. For treatment, the side usually doesn't play a big role.
Does trunk training really help?
It's no guarantee, but a strong trunk stabilises the upper body when running. Many runners report that side stitches become less frequent with it.
How long does an appointment last?
A physio appointment at Kineo lasts 30 minutes. In the first session we clarify the cause and start straight away with treatment and exercises.
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Book an appointment
Do side stitches slow you down on every run? Book your appointment at Kineo Seefeld and we'll look at your trunk, breathing and running style together.
