If, like many runners, you get that undeniable pain in your side or stomach part-way through a run or race, you’ll know exactly what it’s like to have a stitch when running.

Often it is debilitating; forcing us to slow down or stop. Try as we might, sometimes we just can’t run through it and we get frustrated and stressed when our race or run is ruined.

But you are not alone: according to research by Morton and Callister 2015 (1), more than 70% of runners reported having the pain of a stitch, and one in five race participants can be expected to get a stitch during the event.

Formally know as Exercise-related transient abdominal pain (ETAP), the stitch is one of body’s mysteries that unfortunately, science just hasn’t been able to get to the bottom of. However, it is known that a stitch is directly related to the abdominal area. And there a couple of common theories that try to explain it:

• Reduced blood flow to the diaphragm causes it to cramp. The logic behind this, is that as we exercise and the intensity or duration increases, the body diverts blood to the working muscles of the limbs. This results in reduced blood flow to the diaphragm and therefore causes cramping.

• The second theory, according to Morton & Callister, is that a stitch could be down to the irritation of the membrane lining of the abdominal cavity. They are keen to point out though, that more research is needed to arrive at a conclusive cause.

There have been various studies over the past 15 years, and although none have been conclusive in finding an absolute cause of ETAP, the characteristics are reasonably well understood:

Pain:

Sharp or stabbing when severe. When less severe, the pain is more like cramping, aching or pulling.

Location:

In the majority of cases, the pain can be identified to a specific spot, although it can be anywhere in the abdominal area.

Source: Morton and Callister, 2015.

Shoulder tip pain:

Pain in the tip of the shoulder has been associated with ETAP from as far back as 1951 (Sinclair, 1951). In the vast majority of cases reported by Sinclair (2), the shoulder pain was on the same side as the abdominal pain.

Age:

According to Morton & Callister, young, active individuals appear to be more prone to getting a stitch – 77% of active individuals under 20 years reported experiencing a stitch compared to 40% of people over the age of 40.

In the research findings, there has been some commonality in factors that can bring on a stitch. These include:

Running:

This is the sport where ETAP occurs more frequently than any other sport. But of course, you knew that which is why you are reading this!

Food and drink:

Eating and drinking before exercise is consistently reported to provoke the onset of a stitch. In one survey, around 52% of individuals claimed that eating before exercise brought on their stitch, while 38% said that drinking before exercise induced the stitch. In another study, 30 out of 35 cases where the people had eaten prior to exercise all experienced a stitch. This is compared to 19 out of 35 cases who experienced a stitch but didn’t eat before exercise.

There appears to be a link between the volume of food and drink consumed the evening before a race and the onset of a stitch during the event (Morton and Callister, 2015). They also state that there does not appear to be any significance in the nutritional make up of the pre-event meal with respect to carbohydrate, protein and fat. It is recognised, however, that more research needs to be done in this area.

There is also some evidence of people reporting stitch pain shortly after taking on fluid at drink stations and this brings us onto a link between sugar and stitch pain.

Hypertonic sports drinks, those that have higher amounts of salt and sugar, have been shown to provoke a stitch far more frequently than either isotonic (same amount of sugar and salt as normal bodily fluids) or hypotonic (e.g. water) drinks. Isotonic drinks seem to induce stitches less frequently than the other two.

Right then, you’re running your race and a stitch comes on. What do you do now? There are a few reported actions that can be taken, The % in brackets indicates what percentage of people have found the action resolved their stitch pain:

• Deep breathing (40%)
• Pushing on the affected area (31%)
• Stretching the affected area (22%)
• Bending forward (18%)

It’s very tricky to give advice on this because we don’t really know what the cause is. But, here are the top tips:

Don’t eat or drink in large volumes closer than two hours before activity. As some people are more prone to stitches than others, they may need to leave three or four hours between meals and activity – especially racing.

Avoid hypertonic drinks (those high in sugar and salt). You may need to replace electrolytes (salt etc), but do so in a way where you are not taking on a load of sugar. Could this be why some people get pain when taking a lot of gels?

Improve your core strength. And when I say ‘core’, I am talking neck to knees. The more you can control the rotation of your torso during running, the better it is. Not only will you go faster for less energy output, but you won’t jiggle your internal organs as much and therefore could reduce your chances of getting a stitch.

Improve your posture. Clearly linked to core strength, improving posture has been shown to reduce ETAP.

Improve your general fitness. It has also been shown that as your overall fitness to carry out running and other activities improves, the instance of ETAP reduces.

Grow old (McCrory, 2017 – in humour) (3). Stitches are less prevalent in the over 40s.

So there you are, we don’t yet know the ins and outs of the mechanics of a stitch, but we do know the type of pain that is caused and where that pain occurs.

We also have a pretty good idea of what we can do to reduce the chances of us getting a stitch, and we have some proven strategies to relieve stitch pain when we get it.

Cited research
(1) Morton, D. & Callister, R. Sports Med (2015) 45: 23. https://doi.org/10.1007/s40279-014-0245-z

(2) Sinclair JD. Stitch: the side pain of athletes. N Z Med J. 1951;50(280):607–12

(3) McCrory P. A stitch in time. Br J Sports Med. 2007;41:125

The post Why do I get a stitch when running? appeared first on RunTeach.

Hydration! With average temperatures starting to rise as we progress through spring and into summer, we are blessed with a few sunny and hot days (for us Brits anyway!). And while the sunshine brings us smiles and joy, it also brings with it a dilemma for us runners: 

How do I hydrate? What do I drink and how much?

As you look out the window, the sky a magnificent blue, you are desperate to get out for your run. But wait… your mind starts racing and a mild panic takes hold.

“Have I drunk enough? Is plain water okay? Do I need to take water with me? I read something about electrolytes, I better grab a bag of them (even though I don’t really know what they are)…. Help, I just want to run and not die, why is it so hard?!”

There is so much confusion around hydration, dehydration, heat stroke, hyponatremia (what?) and self-drowning (yep). Now add in euhydrated, hypohydrated, hyper-hydrated, hypotonic, hypertonic, isotonic… arghhhhhhhhhhhhh – can I go out and run yet?

Keeping hydrated is a serious business and yes, behind the scenes there is a lot going on. But once you have a basic understanding and a feel for how your body reacts under different conditions, it can be pretty simple. Don’t allow yourself to get drawn into the marketing hype.

Let’s start right at the beginning….

Fluid intake is episodic (every now and again). Fluid loss is continuous (all the time, no matter the weather, climate, temperature, etc)¹.

Under normal conditions, our body regulates our water intake and output. While it fluctuates throughout the course of a normal day, it usually gets back to the same point over a 24-hour cycle².

Our little challenge is to deal with potentially larger fluctuations when we are going out for a run. More-so over longer distances, higher intensity, and higher temperatures and greater humidity. Add in to this the fact that we don’t want to be stopping for a pee every 10 minutes ( I would have got a PB but….)!

What is hydration and dehydration?

There are several definitions about, but all are very similar:

Hydration is…

the process of causing something to absorb water ³.

The process of combining a substance chemically with water molecules ⁴.

the process of making your body absorb water or other liquid ⁵.

Dehydration is…

The process of losing or removing water or moisture ³.

Dehydration is a condition that results when the body loses more water than it takes in ⁶.

A condition caused by the excessive loss of water from the body, which causes a rise in blood sodium levels ³.

We classify dehydration into one of three categories:

1. Mild dehydration
2. Moderate dehydration
3. Severe dehydration

Most of us have a pretty good idea about what hydration and dehydration is, and we know we need to keep hydrated. But what exactly does keep hydrated mean?

First, let’s look at what the continuous loss of water from the body – why does it happen? Well, we lose water by…

Sweating, peeing, pooping, tears, saliva (spitting) and breathing.

These are normal everyday events for most of us. We also lose water through less frequent events (depending on how often you are adventurous with your nutrition perhaps…)…

Diarrhoea, vomiting, fever, excessive sweating, excessing peeing (for example diabetes and some medication such as water pills).

But, we also take water in from a variety of sources:

Direct water intake, as part of other fluids/drinks and through food.

So this now brings us to the term euhydration. This is the state at which our body is in hydration/dehydration balance:

Normal state of body water content; absence of absolute or relative hydration or dehydration ⁷.

And this is the state that we should be starting all our running in. It’s what I call “properly hydrated”. If we start a run properly hydrated, and depending on how we get to properly hydrated (more on that in a minute), we are much better able to determine our fluid needs for that run.

The most simple indicator that we can use to determine whether we are properly hydrated is urine colour:

While feelings of thirst, dry lips and headaches can also provide clues, these symptoms can be from other things as well so urine is pretty reliable. Be warned though, some foods and supplements can cause your pee to change colour – too much vitamin C can make it go bright yellow, for example.

The NHS recommend between 1.6 and 2 litres of water per day, but that includes the fluids you get through food intake (approximately 20%). But we need to adjust this for the environment, our exercise intensity, and our individuality. We all sweat at different rates, so we lose water at different rates.

But it’s not only water that we lose. This brings us to electrolytes. Electrolytes are substances that create an electricity-conducting solution when mixed with water. Common examples of electrolytes are Sodium, potassium, chloride, calcium, magnesium, and phosphate. They are vital in the chemistry of our bodies, and are usually replaced through normal food intake.

However, when we sweat heavily we lose more than we can replace. This is also the case with vomiting and diarrhoea. This loss is then made even worse when we try to replace the lost fluid by drinking a lot of plain water. This dilutes the fluid in our bodies further, and effectively ‘washes’ the sodium (salt) out. This is bad news and can result in hyponatremia, a condition where the sodium level in the blood is too low. Our cells swell and this can cause a host of health issues, being fatal in extreme cases.

Overhydration, where we are taking on too much plain water, is a significant cause of hyponatremia. We see this condition in long running events such as the marathon. Some runners take water at every aid station and end up severely overhydrated – sometimes with fatal outcomes.

Getting the balance right

So now we are properly hydrated before we start, we need to determine whether we need to drink fluid on our run or whether we’ll be okay until we finish. Sometimes this can be an educated guess (for example a cool 5k or 10k, or a hot 20 miler), and sometimes we need to think a bit more about it. A lot comes down to experimenting and personal feedback. There are online sweat tests that can be taken to help determine your sodium loss per hour. This can help you decide what type of fluids you are going to need.

In my own experience, drinking up to 500ml of either water (if going for a short, cool run) or 500ml electrolyte solution (for everything else) in the hour before running gets me to my starting point of properly hydrated. If it is going to be an intense, long or particularly hot session, I’ll drink more than 500ml of the electrolytes solution or make that solution stronger. A lot will depend on what I have drunk up to that point of the day.

Also worth considering is that if you eat a low carbohydrate, low refined food, or low sodium diet, you made need a slightly higher level of sodium on certain days (all these diet types are generally low salt). However, this will also depend on how long you have been “low salt” and whether your body has fully adjusted to that or not.

A study published in the Journal of Clinical Nutrition¹ in 2015, looked at the water retention rates of a range of drinks. They did this to see if certain drinks could help us retain the water in our fluid intake for longer, therefore being quite practical in situations where we can’t always take on frequent amounts of fluid – and where we don’t really want to be peeing all the time. Sounds ideal for runners.

All the drinks were measured against the baseline of plain water, and the drinks included: plain water, sparkling water, tea, coffee, cola, diet cola, a specific electrolyte solution (oral rehydration solution), a sports drink, orange juice, lager, full-fat milk, skimmed milk and a few others.

Conclusion

They concluded that over after a four hour period, the amount of urine from the specific electrolyte solution (oral rehydration solution) and the full-fat milk was less than that of pure water. This means they had better water retention properties than plain water. All the other drinks were the same as plain water.

Even over a two hour period, only the electrolyte solution, full-fat milk and skimmed milk were better than water at retaining the water.

So what does that tell us? While no research can tell us how your body will react, it does seem clear that drinking a solution of water and electrolytes is better than water alone when we want to stay hydrated over a longer run. If we are heavy sweaters or otherwise have low salt diets, we can probably come to the same conclusion – drink water with electrolytes, but not the commercial sports drinks as they don’t seem to help in this situation, and most still contain quite a lot of sugar. There are however, quite a few specific hydration or electrolyte products available from companies such as High5, SiS, SOS (20% discount code: CHRIS20), OSMO, elete, etc.

So which electrolyte product should I use? We’ll get onto that in the next post 😉

The key here though, is to experiment with different strategies to find the one that works for you. I prefer to be properly hydrated or even pre-hydrated before I run. Pre-hydration, as far as I’m concerned, is topping up both my water and electrolyte levels before I run – especially before long, hot or intense sessions. That way I know my starting point is good. I also drink an electrolyte solution after I run.

By pre-hydrating and through experimenting, I have also trained myself to run 15 miles or so on a cool day, without needing to take fluids with me. On a hotter day, I always take an electrolyte solution if my run is going to be over 10k. But, I don’t carry a water bottle in my hand. Why?….

One last thought…

Carrying things in hands while running changes your running mechanics. Carrying a water bottle while running will alter the way you run, and over time this could lead us down all kinds of avenues we would rather not go (injury mainly).

Instead of carrying the bottles in your hands, use a race vest or hydration vest. I prefer a race vest and then put a small bottle (or two) in the carrying pouches. I find that with hydration vests (CamelBak, etc.), the water gets warm from being against your back and that’s just yuk!

So there you have it:

1. Use your pee as an hydration guide
2. Always try and be euhydrated (properly hydrated) throughout the course of a day, adjusting for your environment. Add electrolytes (even at work) if necessary
3. Experiment with plain water and also with electrolyte solutions during and after your run
4. Prehydrate (not overhydrate!) and train yourself progressively to run further/harder without needing to carry fluids. The keys are train and progressive.
5. Be sensible and listen to your body, and stay safe. Too little or too much is never a good thing

As an ambassador for SOS Hydration, I am able to offer everyone a 20% discount. I love their product, which is why I was keen to become an ambassador for them. It is easy on the stomach and certified organic. You can buy SOS from:

SOS website and use the discount code: CHRIS20 for your 20% off

(https://sos.refersion.com/c/8a7923)

REFERENCES

1. 1. Ronald J Maughan, Phillip Watson, Philip AA Cordery, Neil P Walsh, Samuel J Oliver, Alberto Dolci, Nidia Rodriguez-Sanchez, Stuart DR Galloway. A randomized trial to assess the potential of different beverages to affect hydration status: development of a beverage hydration index
   2. Leiper JB, Seonaid Primrose C, Primrose WR, Phillimore J, Maughan RJ. A comparison of water turnover in older people in community and institutional settings. J Nutr Health Aging 2005;9:189–93.
   3. Dictionary.com
   4. https://en.oxforddictionaries.com/definition/hydration
   5. https://dictionary.cambridge.org/dictionary/english/hydration
   6. https://www.nhs.uk/conditions/dehydration/
   7. www.medilexicon.com/dictionary/30690

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