More on Side Stitches

This is one of many follow-up questions on side stitches that I will try to clarify some points.

Hi, Thanks for this useful site. I have been running for several years and for the past several months approximately 20 or so miles a week. I have never had issues with stitches except for the last 4 weeks at the tail end of my long run (10 miles). It is always around the same time (9.67 miles), where I have to run a long downhill, and it is usually after having second gel pack (which doesn’t cause any issues the first time). It feels like a bubble in my right side that starts to move over my belly button and causes such pain that I have to stop, double over and can barely finish running. I wonder if I should just skip the 2nd gel? Can’t tell if I’m getting too much fluid or not enough. It has been extremely hot and humid, I generally take a small swig of coconut water every 10 min or so but continue to feel thirsty. I do have asthma and although I’m on practically every inhaler under the sun, my asthma is not always well controlled so I tend to breathe heavily especially on hill ascents and descents. I try putting my hands above my head (no help), to slow down (no help). Any thoughts you have are welcome. Thanks.

I’ll start with this: the limited mileage you run could be contributing to your stitches in a long run. Your long run is 50% of your entire weekly mileage. That is hefty. So, look at your training program. You do not mention paces and paces are an important ingredient here. If you don’t have good quality on your other days and you are just jogging a couple miles on a couple days – it may simply be a conditioning issue. You need a more well rounded program. Or, you simply need a longer time to accommodate to a 10 miler.

You have two or three key signs that I think are more likely your problem. The fact that patterns are noticed and that they are new patterns is important. That first pattern – downhill running at a specific point on a specific course – indicates to me that the downhill running is an issue. You do not mention if other similar downhill running (same grade on other courses) elicits this.

The second pattern is the cramping coinciding with use of the gel pack.

A third contributing point might be heavy breathing uphill combined with the dramatic change to downhill (due to body mechanics and/or asthma) which can often elicit cramping.

The first step is to experiment and isolate the most dominant cause (or combination of causes). You’ll need to try each possible “intervention” a couple times to be sure it wasn’t just chance or a good-day bad-day thing.

1. To isolate the intake issue: the easiest is to skip the second gel pack. For a 10 mile run there is little need for this. Unless this run is taking two hours You’re not running a marathon – so drop it.
2. To isolate the hill issue: run downhills of a similar grade on other courses at differing mile points along the run. Take note if and when any cramping occurs.
3. To further isolate the hill issue: run uphill fast (elicit hard breathing) then keep running hard over and downhill.

Note any patterns; hopefully you will now know that one (OK or more) thing is a primary culprit.

Possible Solutions:
If it’s the gel then it’s easy – stop using them.

If it’s downhills – start practicing them. This includes working on posture and control. It is not something that just happens. It must be practiced. Similarly if it’s the pattern of transitioning from uphill to a downhill

If it’s breathing – and you have symptoms on uphills but you do not have symptoms on flatlands – you need to get in better condition and work on uphill running technique. Relax – run more upright – don’t lean too much into the hill.

If it’s breathing and you have symptoms on various parts of a course on differing days etc, you’ll need to look to your medications and conditioning. Most often with distance runners and EIA it either is bothering you or it isn’t. So if it is intermittent on a single run – that would be highly unusual that it is your asthma – it’s most likely conditioning. On the other hand if it starts out a bad day breathing and pretty much persists – it’s most likely the asthma. Having EIA can be problematic and you may need further experimentation with combinations of medications. Since causes of asthma are wide ranging the medications that work/don’t work are different by individual as well.

I have never found relief with the old “hands over head” technique though to this day some coaches advocate it. Here is my alternative (which doesn’t work 100% of the time but more than the 0% “hands over head”). Put your hands on hips and as you inhale help your breathing by pushing down slightly on your hips to elevate your shoulders. This will “open” your chest more naturally and stretch at the waist just slightly. As you exhale drop your shoulders and get full exhalation. Try it – see how it works for you.

As far as hydration goes, it can contribute to cramping. You need to isolate whether you do or do not hydrate well enough. I don’t know anything about coconut water so I cannot address whether this in fact is contributing to the problem. It is an unusual fluid choice. It is advised that when taking in a gel that you should only use plain water to dilute it.

To know if dehydration is contributing to the issue weigh yourself. The easiest test is weigh yourself naked before and after the run and figure out the percentage of body weight lost during the run. Your goal is to keep it to less than 3%. If it is more than that you aren’t getting enough fluids in you and you’ll need to revisit your whole hydration strategy (pre/during/post workouts).

As far as using the inhaler and breathing specifically, practice belly breathing; purse your lips on exhalation; tighten abs as you exhale; for some tighten them while inhaling helps.

Finally, on the conditioning front; if you are accustomed to jogging similar paces day in and day out you will greatly benefit from a variety of paces including very fast running to force your respiratory muscles to work and get in condition. This is different than general core work. (Though core work can help too.) I am certainly an advocate of modest mileage training but to make it work there has to be quality miles.