Running: Preventing the Side Stitch

By Dr. Donald A. Ozello DC

Las Vegas Informer

Prevent painful side stitches, also called side cramps, with several easy steps. The scientific term for the side stitch is “Exercise-related transient abdominal pain” (ETAP).

The side stitch is common among runners. Not technically an injury or an illness, the side stitch, is a frustrating condition that negatively affects performance. The good news is the side stitch is preventable.

The exact source of ETAP is yet to be determined by exercise science. Most likely several contributing factors exist. What is known is that the diaphragm plays a major role.

The diaphragm is a muscular sheath which separates the chest cavity and the abdominal cavity. It spans the lower edge of the ribcage and is the primary breathing muscle.

The side stitch is described as a sharp, stabbing pain under the lower edge of the ribcage. It is more common on the right side then the left side. Pain in the same sided shoulder usually accompanies the side stitch.

The side stitch can occur in runners of all experience levels and fitness levels. It is more common in less experienced runners and lesser conditioned athletes . The side stitch also affects swimmers and horseback riders. It is less common in older athletes. Gender and body mass index do not seem to be factors. It is more likely to appear when running downhill then during uphill or level ground running.

Chief contributing factors to the occurrence of side stitches include: Fitness level, core strength, breathing practices, warm-up, nerve impingement, running spinal posture and pre-race nutrition. Most likely a combination of these factors induces the side stitch.

Fitness Level: Higher conditioned runners can maintain normal breathing, also known as belly breathing, longer than new runners and lesser conditioned athletes.

Normal breathing consists of the diaphragm ascending and descending as the primary source of breathing. During inhalation the diaphragm contracts and moves downward. The downward motion creates a vacuum in the chest cavity and air flows in. The downward motion pushes the belly outward. In most cases, as overall fitness level improves diaphragm strength increases and the side stitch occurrence lessens.

Core Strength: Think of the diaphragm as one of the core muscles. Strengthen your diaphragm with breathing exercises. Strengthen your entire core with consistent usage of a wide number of exercises.

Breathing Technique: Experiment with a variety of breathing techniques to determine what works best for you in preventing ETAP.

A commonly used breathing method is to exhale when your left foot strokes the ground. The theory behind left foot exhalation is that the side stitch is caused by the liver pulling on the diaphragm.

The liver, the heaviest internal organ, is located on right side. It is connected to the diaphragm by ligaments. During exhalation the diaphragm is rising. When the right foot strikes the ground the liver is pulled downward. This combination exerts a great amount of pull on the diaphragm. The repetitive pulling induces the diaphragm to spasm. The muscle spasm is the reason for the side stitch.

Exhaling when the left foot strikes the ground lessens the liver’s pull on the diaphragm. The lower degree of pull on the diaphragm lessens the possibility of spasms.

Warm-up: The diaphragm is a muscle and needs to be prepared for exercise just like the other muscles. This is best accomplished by starting at a slower pace or performing a pre-run.

Start at a slower pace then increase speed to allow the breathing muscles time to prepare for the intensity of your run.

If timing yourself, execute a short slow pre-run of two to five minutes. This properly prepares the diaphragm for your faster pace timed run. Once your pre-run is complete proceed to your starting line and start your timed fast paced run.

Pre-race Nutrition: Eating a heavy meal or drinking a large amount of fruit juice before running is a precursor to ETAP. This common mistake is usually a major contributing factor of side stitches in veteran runners. A heavy meal in the stomach and intestine weighs down the diaphragm. The extra pull elicits muscle spasms in the diaphragm.

Nerve Impingement: Impingement of nerves contributes to muscles spasms. The diaphragm is innervated by the phrenic nerves. The phrenic nerves originate from spinal nerve roots on both sides of the spinal cord in the neck. These long nerves originate in the neck and travel through the chest cavity to supply nerve signals to the diaphragm.

Impingement on the nerve roots at the vertebral level in the neck can lead to impeded nervous communication to and from the diaphragm. The impeded nerve flow contributes to the diaphragm not working at one hundred percent of its capabilities and to the formation of muscles spasms.

Running Spinal Posture: The spine is vital to athletic success. The spine is the nucleus of movement. Proper spinal posture is imperative to maximizing breathing and minimizing injuries.

Runner who hunch forward at the upper back are more prone to ETAP. Hunching forward, an exaggerated forward bend in the thoracic spine, restricts motion in the ribcage. The ribs cannot expand properly and the diaphragm cannot rise up and down properly.

Solution: The exact genesis of ETAP is unknown to exercise science. Spasm of the diaphragm is most likely the reason for the symptoms. Several factors can cause the diaphragm to spasm.

Follow the recommendations in this article to help prevent ETAP.

Exercise with proper technique on a consistent basis to increase your aerobic and anaerobic fitness. Strengthen your diaphragm with lung strengthening exercises. Develop stronger core muscles with a plethora of exercises.

Formulate pre-run nutrition strategies that work for you. Avoid heavy and fatty meals prior to running. Stay away from highly concentrated fruit juices before running. Drink water for hydration.

Warm-up thoroughly before running. A comprehensive warm-up helps lower the risk of injury and performance limiting conditions. The side stitch is no exception. A few minutes of slow running prepares the diaphragm for more intense exercise and decreases the risk of ETAP.

Breathe in a manner that prevents the side stitch. Try exhaling as your left foot strikes the ground to lower the forces placed on the diaphragm.

Run in good posture. Do not slouch. Maintain a good position in your spine. Keep your neck in line with your spine. Allow your ribcage to expand and move in a healthy manner. Better positioning of your spine and ribcage allows the diaphragm to move properly. Better diaphragm movement promotes healthy breathing and reduces the possibility of ETAP.

Receive chiropractic treatment on a consistent basis. Chiropractic care re-establishes proper skeletal motion, optimizes nerve flow and maximizes function.

Chiropractic adjustments to the cervical spine help remove impingement on the nerves which transmit signal between the spinal cord and the diaphragm. Chiropractic treatment to the thoracic spine, lumbar spine and ribcage improve motion and function in the spine and ribcage. Proper skeletal motion and improved nerve flow helps decrease the possibility of the side stitch.

Conclusion: Employ these methods to prevent the side stitch and improve your athletic performance. Include the above recommendations in your health and nutrition strategies to lower the risk of ETAP and to improve your fitness. Prevent the side stitch and maximize your running performance.

Dr_Donald_A_Ozello_thumb_medium150_Dr. Donald A. Ozello DC

Dr. Donald A. Ozello DC is the owner and treating doctor at Championship Chiropractic. 8871 W. Flamingo Rd, Suite #202, Las Vegas, NV 89147.  His web address He can be contacted at (702) 286-9040 and

Dr. Donald A. Ozello’s mission is to educate and inspire others to live healthier, fitter, more functional lives.

Dr. Donald A. Ozello DC is the author of the book “Running: Maximize Performance & Minimize Injuries: A Chiropractor’s Guide to Minimizing the Potential for Running Injuries.” He writes a weekly health, fitness and nutrition column for The Las Vegas Informer. He is published in OnFitness and He has educational health, fitness and nutritional videos on Informer TV, and YouTube.

Dr. Donald A. Ozello DC proudly handles Standard Process Supplements and Foot Levelers Orthotics.

Dr. Donald A. Ozello DC is an award-winning public speaker. He has spoken to numerous groups on the importance of health, fitness, exercise, ergonomics, nutrition and injury prevention.

Dr. Donald A. Ozello DC is a fitness enthusiast. Functional kettlebell training, running and bike riding are his favorite types of exercise.

Before pursuing his career in Chiropractic, Dr. Donald A. Ozello DC served in the United States Navy aboard the USS Bremerton, SSN 698.

0.00 avg. rating (0% score) - 0 votes

Leave a Reply

Your email address will not be published. Required fields are marked *

Join the Informer mailing list

Check your email and confirm the subscription