How to prevent a runner’s side stitch… maybe

I still remember my worst stitch. I was 12 years old. Our school class had trooped off to a local park late in the autumn term to do one of those British weather-inflicted cross-country runs that teachers think are fun, and that kids think are stupid. We were deployed like mini Marines on manoeuvres and on this day the overused paths were peppered with deep puddles and cloying mud from frequent rain; our activity was more of an obstacle course than an afternoon jog.

I quickly worked out the secret sauce for success in these activities; the technical name is called being bothered. At 12 years old most kids couldn’t be. If you were in the ‘Not Bothered Brigade’ you had two tactics for keeping for your feet dry: hug any tree holding the high ground either side of the obstacle and then jump when necessary, or carefully pick your way through brambles. The NBBs would invariably return from their exertions with chests covered in verdant moss, and with tiny red rivulets on their arms and legs. Apparently, the possibility of blood was better than the inevitability of mud.

I was looking forward to getting back to the showers early and was squelching along, feet caked in mud, minding my own business, when an invisible knife pierced my side just below the ribs. My phantom running buddy pushed the blade in further, and then twisted it. I like to think I didn’t scream, or at least yelp. I probably did. I paused for a time and recall looking back; the blood warriors were still out of sight and I was on my own. I eventually began walking again, ever more briskly, but the stitch remained. In fact it didn’t even get better until some time after the end of the run, and as is the case for many things in life I simply learned to live with it for as long as I had no choice.

The next time it happened I had a teasing warning, as though my hidden tormentor was playing with me. I tensed in anticipation, waiting, waiting, until the blade finally made its way through the side door and just sat there, inside me, like the dodgy relative who turns up on your doorstep unannounced, eats all the best cookies, and who can’t take a hint that it’s time to leave… not realising it was never even time to arrive. 

Looking for a cure

A stitch is what I always called it but the name doesn’t really matter. Others might call it the runner’s stitch, side stitch, side cramp, ‘ETAP’ (exercise-related transient abdominal pain), etc. We could call it Fluffy Bunnykins and it wouldn’t make it any less annoying or painful. It can happen when I am running fast, and even when I’m running slowly and it feels like a knife or a needle, although I understand others can experience it differently, perhaps a dull ache. It was of no relief to eventually learn it had affected Olympians and marathon greats like Haile Gebrselassie and Deena Kastor.

From time to time I’d research causes and solutions. I tried all of the preventative measures, with varying levels of enthusiasm:

  • don’t eat too close to a run
  • don’t drink orange juice before a run
  • don’t eat too much before or during a run
  • don’t eat spicy food the night before or on the day of a run
  • don’t have too much sugary food before or during a run
  • build up your tolerance to sugary drinks (woo hoo!)
  • develop your core strength
  • develop your flexibility
  • warm up properly
  • become fitter
  • get older

All of these are good advice anyway, apart from avoiding sugary drinks bullet point. (It’s hard to do a long run with no carbohydrate.) The getting old thing is also to be avoided where possible, unless you’re as ageless as Audrey Hepburn. Audrey Hepburn has nothing to with stitches or running, at least as far as I know, but any blog post is going to seem a little classier with a light sprinkling of Audrey. She’s awesome! Just saying. 

I am now older, fitter, stronger, less spicy, and after all my sugary runnning I’m also a damn sight sweeter. The stitches are coming less frequently than they used to but Fluffy Bunnykins still keeps turning up unannounced, expecting a cup of tea and wanting to eat my Chocolate HobNobs and Jammie Dodgers. (The UK has some of the best names for cookies and biscuits.)

If prevention wasn’t working, could a cure be the solution? I have tried those too:

  • Carrying on running while pushing my fingers into the side that hurts (Which sadist…!?)
  • Carrying on running and timing my breathing so I breathe out when my foot on the side of the stitch hits the ground (before, presumably, deducting my date of birth and dividing by the number I first thought of)
  • Slowing down my run, or walking
  • Stopping the run to fold myself over at the waist and breathe slowly and deeply
  • etc.

The only things that have worked for me are slowing or stopping.

I think I found the problem

In his book, Born to Run, Christopher McDougall notes that unlike most animals the breathing of humans is disconnected from our running pattern. Contrast this with a cheetah, whose leg motion acts like a bellows for its lungs. I.e. its lung activity is directly connected to its leg activity. A cheetah is fast, but it cannot last long. Homo sapiens, however, can take long deep breaths or short sharp breaths, mixing up the pattern as and when needed, regardless of our pace or the motion of our legs. We can’t outrun a cheetah over short distances, but we can outlast a cheetah over long ones. This flexibility in the way we breathe, which should be an asset, was also my problem. Periodically I would do it all backwards, sometimes when I was running quickly, sometimes when I was running slowly.

Yoga practitioners and freedivers will be familiar with the three part breath, which emphasizes the importance of breathing not just into the top of your chest, but also into your belly. When I was running, I was doing two things wrong:

  1. I wasn’t breathing deeply enough into my belly, and so I was reducing the amount of oxygen taken in with each inhalation and
  2. When I did breathe into my belly, I was squeezing in my tummy just as I was trying to fill it with air, and pushing it out when I was trying to exhale.

That second point is really important… and it makes no logical sense. I was putting my internal organs under strain by asking them to make the space inside my abdomen smaller just as I was trying to fill it, and to make the space bigger just as I was trying to empty it. The Far Side’s “Middle School for the Gifted” sprang to mind.

 

Somehow, over the years of being more bothered than most 12 year old kids, I had developed this totally incorrect habit. Audrey would be horrified.  

Learning how to breathe

My solution for addressing my stitches, other than becoming older, wiser, more sweet, less spicy, etc. is now to focus on my breathing, and to incorporate breathing into a mental checklist that I go through every mile or so on my run:

  • am  I relaxed?
  • how is my nutrition and hydration?
  • how is my cadence?
  • am I landing mid-foot?
  • am leaning?
  • am I belly breathing?
  • am I pushing out my belly as I breathe in /squeezing in my belly in as I breathe out?

 

Credit for the above image to: https://yurielkaim.com/belly-breathing/

I still catch myself breathing incorrectly but at least I’m aware, and I hope that if I keeping checking in with myself the new habit will eventually become engrained.

A final word

The latest word on stitches is that the issue is not Fluffy Bunnykins at all but rather the parietal peritoneum. (If only I had known this earlier in the article.) The connection between the parietal peritoneum, a membrane around your abdomen, is… going into too much detail. Instead I think it’s safe to say that when it comes to stitches, lots of things can bring it on and the trigger can vary from person to person because we’re all individuals.

Endurance runners know there is no one size fits all solution. In much the same way that one form of nutrition is great for one person and by hated by another, we all need to find our own path when we suffer discomfort. I’d advocate addressing whatever will bring most benefit quickly. If poor eating just prior to a run is your kryptonite, then that’s what I’d focus on first. However, if you walk around stiff as a board all day then I’d focus on your flexibility. If you’re not sure then you might need to hit a few tactics all at once.

This article says breathing is the solution. Well, it’s my solution. I think I had slowly eliminated the larger risks until I reached the point where breathing was simply the next big thing to address. Even now, as I reflect, it may not address the issue for the reasons I believe. Maybe going through that breathing check just reminds me to address poor form. Maybe the focus on breath distracts and relaxes me – a breathing, running meditation of sorts. Maybe it’s not down to breathing at all but rather because I just got even older. Maybe I don’t need to understand why it works at all; right now I only care that it seems to be doing the job.

Cool books:

Disclosure: the links to the two books below are affiliate links, meaning, at no additional cost to you, I will earn a commission if you click through and make a purchase. 

Other online references:

https://www.popsci.com/what-is-side-stitch

http://www.abc.net.au/news/health/2017-11-01/9089048

http://www.athleticsweekly.com/performance/how-to-avoid-a-stitch-59637

http://www.mountainmadness.ca/documents/Runners_Stitch_by_Jenn_Turner.pdf

https://runnersconnect.net/side-stitches-abdominal-pain-causes-and-treatments/

https://www.verywellfit.com/how-do-i-get-rid-of-a-side-stitch-2911699

https://www.runnersworld.com/training/a20788032/four-ways-to-stop-the-dreaded-side-stitch/

https://www.runnersworld.com/health-injuries/a20838539/how-to-beat-side-stitches/

 

 

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Practice Doesn’t Make Perfect

I’d hear running coaches extolling the virtues of core strength, stretching, speed work, etc. I’d acknowledge the benefit of their experience, and then immediately ignore it. I went back to doing what I liked doing, which was running long and slow. I was running because I enjoyed it, and who takes up a hobby to do the bits in it they don’t like?

As time progressed, I was telling myself there must be more to this hobby, and I did want to run faster. I had a choice: either do more of it, or drop it for the next activity of interest. I chose to do more. Except I continued to even more of the bits I liked, until I got a knee injury. I went to a physical therapist called Molly. For the sake of this story, we’ll call her ‘Molly’, because that was her name. [Her name isn’t relevant to this story but I often come across books where names have been changed to protect identities, and since Molly was great, I’ll leave hers in place.] She had me lie on my side and raise my upper leg in the air. She then asked me to hold it there and resist, as she pushed down, with one finger. I had no response, and my leg collapsed back down to its partner. The coaches had been right about core strength. Who knew?

That first visit to Molly caused me to revisit my own know-it-all attitude to those running coaches. I decided to use my running time differently and redeployed some of it in strength training. I found myself running faster, despite reducing my weekly miles. I expanded the approach, and took some more time from my long runs to give to speed work. 90 minutes of long running might translate to 45 minutes of speed work; I was spending even less time running yet this too was helping me go faster. I used that ‘spare’ time in yoga, or sleep. It was great. There was also the added benefit of less time running meaning less chance of injury. That year, I achieved personal best times in marathon, half marathon and 5km.

I’ve always liked the musical rhythm in the saying, “If you keep doing what you did, then you keep getting what you got.” I was reminded of that saying (which I first heard from DiNozo, on N.C.I.S.) as I listened to a Freakonomics podcast on ‘being great at absolutely anything’. That podcast cites the source of the perfectly round 10,000 hours of practice required to become an ‘expert’. The figure of 10,000 was launched into the public consciousness by Malcolm Gladwell in his book, ‘Outliers’. I haven’t spent anything like 10,000 hours doing anything of note. I’m not absolutely great at anything, but the podcast was a useful reminder on the wise use of time when you want to improve. You need to do things that you’re less inclined to do. More importantly, you need to live, for much of the time in a place of discomfort.

We fall into comfort zones either because they are things we like doing, or because we have carved grooves for ourselves that might once have been uncomfortable, but have now become too familiar for us to leave. Growth comes when we push ourselves outside of these familiar furrows but doing so is draining, and not just physically. It takes mental and emotional energy to live in a state of discomfort. And it’s not enough to apply the correct effort; we need to apply the correct effort correctly, with ‘best form’. Practice doesn’t make perfect; perfect practice makes perfect.

My trajectory isn’t steep. I plateau a lot. I need to recharge those emotional and mental batteries so that I can take another run at improvement. It comes. I slip back. Sometimes improvement seems to come from nowhere. I like those unexpected leaps in capability where you suddenly just ‘get it’, and you’re not always sure why and when it came the way it did. Those leaps are a spur to further improvement. Those leaps never comes from a comfort zone.

I now know how to train, and the more time I spend in that zone of discomfort, the easier it becomes. In a way, that zone of discomfort becomes a sort of comfort zone in its own right. I’ve observed that I only needed to find this zone in one activity for me to be able to apply it to others, like practising a musical instrument, or learning a language. As my Tai Chi teacher used to say, “having it is less important than knowing how to get it back when it’s lost.” So much is possible if you can find comfort in the uncomfortable.

 

Getting to the Start

During the mid noughties I decided I wanted to run a marathon. Applications for the race I wanted to run open up nearly a year in advance, in April, but you have to wait until around October to find out whether you succeeded in the lottery draw for places. At the time I lived barely half a mile from the start line of the London Marathon. I applied, and I began to run. Not everyone is blessed with the rich training ground I enjoyed.

Set in southeast London, Greenwich Park is full of wonders: deer, trees that date back to the mid 1600s, and a line in the ground separating the east of our planet from the west. The National Maritime Museum runs along the bottom of the park, near the river, and later provided the backdrop for the equestrian events at the 2012 London Olympics; the museum houses treasures from Captain James Cook and Admiral Horatio Lord Nelson. (Although that title seems a bit of a mouthful, his full title is almost as impressive as his deeds.) Looking down on this museum, from atop one of the highest points of London, is the 400 year old Royal Observatory, whose own museum houses John Harrison’s marine chronometer, the device that solved the problem of longitude, and arguably helped the British Empire reach the extent that it did. The park is truly an embarrassment of riches.

When Greenwich Park became too small for my running, I ventured to run behind it, on Blackheath Common. With an elevation of  about 150 ft (50m) it could get very windy, and you sometimes had to take care not to entangle yourself in the lines of the many kite fliers taking advantage of the flat expanse of land. On occasion, I even ran under the River Thames, through the foot tunnel on the other side of the 18th Century ship – the Cutty Sark – once one of the fastest sailing ships in the world.

That summer was a glorious exploration, and so as I write about this time, nearly a decade later, I can’t even recall the extent of my disappointment when I received the email telling me that I didn’t get a place for the following year’s race. I took the winter off entirely and then reapplied.

The exploration and education of my own city continued the following year. Marathons are not as long as the training required to prepare for them, and even the park and heath, which had seemed enormous when slowly walking them with family and friends, quickly shrank in size. My typical training session was soon taking me in excess of 14 miles, and I uncovered parts of London I had never known existed, like Eltham Palace, an Art Deco wonder, once owned by the millionaire Courtaulds, and still displaying some of the original 15th Century Tudor architecture from the original structure. When I received the email telling me I had a place, I continued running, this time through the streets, and through the dark nighted London winter, where the sun rises around 8am and sets before 4pm.

At that time, I had never heard of iliotibial bands, the gluteus medius, or foam rollers. Knee pain caused me to pull out of the marathon. I thought running was uncomplicated (and now, years later, I know more about anatomy, physiology, and running related injuries than I ever thought I needed).  Luckily, I was able to roll my place into the next year’s race. When the same thing happened the following year, with the same knee, I lost my spot in the event entirely. I went to a specialist in body movement, who told me I just wasn’t designed to run a marathon. I gave up. Sort of.

In 2009, I moved to Chicago. I found myself working with a crazy Venezuelan who thought it might be fun to run the Chicago Marathon. Curiously enough, I found myself once more living just half a mile from a start line. Friendship, and a bloody-minded attitude, prompted me to sign up. There was no lottery this time, I was in. WE were in.

For the whole of 2010, whenever anyone asked me my marathon goal, I gave only two responses: to get to the start line, and to have my knees in one piece when I was 50. Time was of no importance. If I hurt, I stopped. I recall doing just that on several occasions. I learned the difference between discomfort and pain When you feel discomfort, you work thought it; when you feel pain, you stop. But after failing to run in the London equivalent, I still recall the ever-present anxiety I felt that I might not even make it to the start one more; I wrapped myself in cotton wool.

Peer support certainly helped. I learned about foam rollers. I learned downward dog, and pigeon’s pose, and I foam rolled my iliotibial bands until I didn’t want to smack someone in the face with a wet kipper. (Anyone who has ever rolled their ITB will know well this urge so smack someone with a fish.) And because I was both more informed, as well as unattached to a time goal, my progress to the start line was more balanced than it had ever been. I was assisted by regular massage, as well as by the articles on injury prevention, which I read voraciously, and by the people with whom I found myself spending time. I was able to get to the start line in 10/10/10 – my inaugural marathon – on a mercifully easy date to recall and convey (regardless of whether you read it in US or UK date formats).

I had spent five years getting to the start of that run. Part of that time was down to the need to accumulate sufficient knowledge, and part was developing my body’s capacity to last. I did finish, but that is irrelevant now. Simply getting to the start was everything. You learn, and you grow, and you assemble a toolkit of knowledge that equips you to deal with the peculiar set of challenges you face. We are all built differently, and my process took as long as it took to coalesce.  It had begun with a simple goal, to run a marathon, but as I look back now, the goal was only important because it caused the journey to be. A goal is important in overcoming inertia, and in generating that early momentum. However, the achievement of a goal is an ephemeral thing, rather it is the journey that is the joy, and the time that journey takes is of no consequence.