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Exercise Related Transient Abdominal Pain (ETAP) AKA “Stitches”

Posted by Filed Under: Running Injuries

1.What is it?

ETAP or stitches are pain in the abdominal area that can occur during certain activities such as running. Studies of ETAP have indicated that up to 69% of runners may experience these painful episodes.

2.What are the causes/predisposing factors of ETAP?

ETAP is widely believed to be due to spasm or irritation of the diaphragm muscle. The diaphragm muscle is used during breathing. It is a dome shaped muscle that separates the chest cavity from the abdominal cavity. When we inhale, the diaphragm moves downwards; assisting in filling the lungs with air. When we exhale the diaphragm springs back upwards.

This is important because a number of organs are attached to the diaphragm by ligaments. The liver is attached on the right side of the diaphragm. So when we run and exhale while landing on the right foot, the liver will pull down on the diaphragm while it is trying to spring upwards. The liver, being the heaviest organ attached to the diaphragm, is thought to cause spasm or irritation to the diaphragm when we have a right foot strike-exhalation pattern.

Breathing and stride patterns are coordinated. Most runners breathe out and step down on the same leg all the time. The most common pattern is a 2:1 ratio of strides per breathing cycle. That is 2 complete strides for one inhalation and exhalation.

Interestingly, the stomach is attached to the diaphragm by ligaments on the left side. Here, a left foot strike/exhalation pattern may cause stitches if the stomach is heavy. This may have given rise to the idea of not running on a full stomach to prevent stitches.

There are a number of other theories regarding the causes of ETAP, but the one mentioned above seems to have gained the most popular acceptance.

3.How can we treat/prevent this problem?

There are a number of strategies for “stitch busting”.

a)Change your breathing pattern. Very simply breathe out while landing on the foot on the opposite side of the stitch.
b)Press up under your rib cage on the right side to elevate the liver slightly and reduce tension on the diaphragm.
c)”Belly breathe”. When inhaling try to expand the abdominal cavity rather than the chest cage.
d)Upside down cycling. Lye on your back with your hands on your hips; elevate your hips and legs above you and make cycling motions in the air with the legs.
e)Try loud grunting- this is supposed to decrease the spasm in the diaphragm.
f)Strengthen your abdominal muscles with crunches and sit ups.
g)Do not take in excessive food or water immediately prior to running.
h)Relax. Visualize a relaxed abdominal area and take deep breaths.

Hopefully these pointers will lead to a happier more pain free running experience.

About Lee Miller D.C.

9536 - 87 Street Edmonton, Alberta T6C 3J1 Phone: (780) 426-6777 Fax: (780) 469-6930



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