Diastasis rectus abdominis (“DRA”) or diastasis recti (“DR”) is by far the topic I’m asked about the most. In my professional experience as a women’s health physical therapist, it is the number one reason for referral! There is an abundance of information regarding this topic, a lot of which isn’t particularly well-founded or evidence-based. And it’s true – the jury (scientific literature) is still out on what is the best way to remedy this condition. But, what I can say is this: it’s different for every person. Let’s take a look at what diastasis rectus abdominis is and why it happens.
If you go back and read my post on abdominal anatomy (https://dramyosborne.com/blog/2019/11/05/the-abdominal-wall/) you will see that each belly of the rectus abdominis is joined by a band of connective tissue called the linea alba. Also recall that the transverse abdominis is the deepest layer that wraps around to form our “core,” and when it contracts, it helps to draw the abdomen inward and regulate abdominal pressure.
You may also recall from my earlier discussion about hormones (https://dramyosborne.com/blog/2019/10/15/hormonal-changes-across-the-lifespan-what-happens-during-pregnancy-postpartum-and-menopause/) that relaxin makes all of our connective tissue more elastic in order to accommodate the growing baby. And guess what? That linea alba is connective tissue, so it can become subject to a lot of strain as your stomach grows, and may stretch so much that the rectus abdominis separates. You can test for DRA by lying on your back, pressing your fingers down into your abdomen at the level of your belly button and lifting your head. You can then feel how much distance is between each belly of the rectus abdominis. Repeat this at 2” above your belly button and 2” below the belly button. Physical therapists often measure this distance in finger-breadths for sake of simplicity. Women may notice that tissue “tents” or protrudes out at midline when DRA is present.
So how do we know who will develop a diastasis? Unfortunately, there isn’t a well-accepted prevalence of DRA, nor are there known factors that predispose women to developing it. But, I can say that as a clinician I’m not particularly worried when a pregnant woman presents with a diastasis. It truly is a common (dare I say “normal”) finding during pregnancy, especially if a woman has ligament laxity or connective tissue dysfunction at baseline. And that stands to reason – if her ligaments are loose or lax in one region, they will be loose throughout her body!
The postpartum period is a bit of a different story. The persistence of DRA is not a normal finding and indicates that something is preventing the linea alba from closing. Now, recall that relaxin can affect connective tissues for up to 6 months postpartum, as hormonal changes associated with breast feeding can also contribute to persistent ligament laxity, which may prevent full closure of the diastasis during this period. However, women can and should learn to appropriately control their intra-abdominal pressure in order to prevent putting repeated strain on the linea alba.
If you read my last post, you’ll remember that I compared the abdomen to a tube of toothpaste. Repeated Valsalva maneuvers or bearing down puts excessive strain outward onto our linea alba, which prevents it from healing. It’s just like ripping off a scab – if we keep putting pressure on that linea alba, it will never heal. Similarly, poor posture will perpetuate poor pressure regulation in the abdomen.
I’d like to point out that DRA doesn’t just occur in pregnant women. Children, men and women who have not had children can all develop a diastasis, and it’s normally due to poor ability to regulate intra-abdominal pressure. This can occur with TA weakness, postural deficits and poor ability to breathe diaphragmatically. Go back and read my last post for more on regulating intra-abdominal pressure: https://dramyosborne.com/blog/2019/11/12/regulating-abdominal-pressure/
Now, I’ve certainly seen that scar tissue can also perpetuate DRA, especially in women that have undergone cesarean deliveries. Think about it – that scar tissue can adhere to the root of the mesentery, which wraps around to the back of our abdominal cavity. If there is a pull of this tissue, it can impair the ability of the rectus abdominis come back together. There’s been some preliminary research to support visceral manipulation as a modality to reduce abdominal separation, and I’ve personally seen some success in incorporating this into my treatments! Check out the article here: https://www.barralinstitute.com/docs/articles/effect-of-visceral-manipulation-on-diastasis-recti-abdominis–dra–a-case-series.pdf
And what this means is that we can develop other areas of dysfunction: the pelvic floor can become hypertonic in an attempt to compensate, or back pain can develop from using the muscles in our hips or lumbar region too much. Once again, there isn’t a lot of solid research demonstrating a correlation between DRA and pelvic girdle pain. However, most clinicians would agree that core strength and coordination deficits are certainly related to pelvic girdle pain, which makes sense: if your TA isn’t strong enough to facilitate closure of the linea alba, it certainly isn’t strong enough to stabilize the pelvic girdle. We also know that core weakness (not DRA, per se) is associated with urinary and fecal incontinence, as well as pelvic organ prolapse. So you can see, it’s not about the DRA itself, it’s about what the separation indicates: ineffective strength and coordination of the transverse abdominis.
As you can imagine, the other question I hear all of the time is: “What exercises should I avoid if I have a diastasis?” The answer: IT DEPENDS! I see some women with 4-finger-width separations that have enough motor control to engage their transverse abdominis and appropriately perform a crunch, while others with small separations can’t so much as initiate a head lift without noticing tissue protrude at their midline. When in doubt, my basic rule of thumb is this: If you can keep your transverse abdominis engaged (think: holding a blueberry in your belly button with neutral spine and no breath holding), then go for it! But, that is a lot harder than it seems. Try it out: could you do a full sit up and not bulge your abdomen outward or move your lumbar spine? If so, you are one strong lady! But, chances are, you lack the strength and coordination of your transverse abdominis to perform higher-demand abdominal exercises without losing that TA contraction. Oh, and if you EVER notice tissue protrude at your midline, skip the exercise.
This leads me to my second-most-asked question: “Can I ever do crunches again?” It certainly seems like crunches and sit-ups get a real bad rep from a lot of PT’s. Are they the most functional movement? No! The most effective? Certainly not! But, I do think that everyone should be able to perform an appropriate crunch without compensation. That said, I never tell my clients that they can never do crunches again. Do you need to learn to control your intra-abdominal pressure and engage your TA before doing them? Absolutely.
This is where PT’s come in. Physical therapists are trained to look at your posture, movement patterns and coordination in order to determine what is appropriate for you in the way of exercise. I can’t tell you how many women come into my clinic after doing some online program that focuses on TA strengthening, just to find that they’ve been engaging their TA incorrectly the whole time. Moreover, I often hear that these programs don’t encourage anything other than TA engagement/breathing techniques, which may not be challenging enough to finally close the diastasis. So if you’re dealing with persistent diastasis after 6 months postpartum, I encourage you to seek at least one one-on-one assessment with a physical therapist, so that you can determine what is standing in your way of healing your DRA!