By Malinda Wright
Most women seem to accept that pregnancy/childbirth changes their bodies. But, what many don’t realize is that some of these changes can be fixed. One of those “fixable” changes includes a diastasis recti (DR) (translation: the separation of the abdominal muscles), which occurs due to pregnancy.
In this post, I’m going to give you a complete overview of diastasis recti, including what it is; how to check for it; how it can be fixed; and why fixing it is important.
What is a Diastasis Recti?
A diastasis recti is a separation of the rectus abdominis muscles, what many refer to as the “six-pack” muscles. This separation occurs along the band of connective tissue that runs down the middle of the rectus abdominis. This band of tissue is called “the linea alba, but for the purposes of this blog, here on out, we’re going to refer to it as the “midline.”
During pregnancy, separation occurs down the midline as a result of the force of the uterus pushing against the wall of the abdomen coupled with the influx of pregnancy hormones that soften connective tissue.
Diastasis recti can occur anytime in the last half of pregnancy, but most commonly occurs after pregnancy when the abdominal wall is lax and the thinner midline tissue no longer provides adequate support for the torso and internal organs.
A small amount of widening of the midline happens in all pregnancies and is normal. In fact, a diastasis recti occurs in about 30% of all pregnancies. Although some women’s midlines spontaneously close to less than a 2 finger-width after labor, for many, the tissue remains too wide. A midline separation of more than 2 to 2.5 finger-widths, or 2 centimeters, is considered problematic.
However, pregnancy is not the only cause of diastasis recti. It can also occur in both male and female children and adults with excessive abdominal visceral fat. Abdominal surgery can also create the separation in both men and women, especially when an incision is made through the midline. For instance, many of our male patients at PHRC who have undergone prostatectomy surgery via the Da Vinci robotic method, often present with a diastasis recti.
Predisposing factors for DR include: obesity, multiple birth pregnancy, and abdominal wall laxity from previous pregnancy or abdominal surgery.
What’s the Problem with a Diastasis Recti?
A diastasis recti can lead to pelvic instability due to abdominal wall weakness. This instability can create a number of problems. These include:
- Abdominal discomfort with certain movements, such as rolling over in bed, getting in/out of bed, and lifting heavy objects
- Umbilical hernia
- Pubic symphysis pain
- Sacroiliac joint pain
- Low back pain
- Pelvic floor dysfunctions, such as urinary, fecal and flatulence incontinence and pelvic organ prolapse
In addition, a diastasis recti can change the appearance of the abdomen. The skin may droop, and some patients may even develop an actual hernia through the midline. Also, some postpartum patients may complain of continuing to look pregnant.
Oftentimes, patients want to know if there is anything they can do during pregnancy to prevent a DR.
My advice to them is to:
- keep their abdominal muscles strong during pregnancy with appropriate exercises,
- maintain proper posture with sitting, standing, and activities, such as pushing the grocery cart,
- avoid sit-up and double leg lift exercises,
- and avoid bearing down when doing activities, such as lifting heavy objects, and eliminating bowels.
Aside from this, I teach my patients proper techniques when getting up from a lying down position, as well as general body mechanics. This includes deploying the “log roll” maneuver when rising from the floor or out of bed. (Log roll how-to: with your torso and head aligned and in one piece, roll over onto your side, then use your arms to help push yourself up to a sitting position.)
Checking for Diastasis Recti
I always check for a DR during a patient’s initial visit at PHRC. The sooner it is caught, the easier it is to rehab. We typically see both postpartum moms and post-abdominal surgical patients at, or after the six-week mark, which is when physicians clear most patients for therapy.
So how common is a DR?
The reality is that about 66% of postpartum women have a widened diastasis immediately after delivery. This is because the tissues at the front of the abdomen are designed to allow the expansion of the belly in order to accommodate a growing baby. However, only 33% of these women will have a diastasis that does not resolve on its own and need intervention.
This percentage is substantially less than what many online sites claim. These sites repeatedly claim that 90% of new moms will have a DR. They also claim that their gadget or program will correct the problem. The fact of the matter is that this information is simply not true, and many unsuspecting moms will just waste their financial resources on a gimmick.
So how does one check for diastasis recti? Here’s how:
- Lie on your back with your knees bent, and your feet on the floor.
- Place your fingertips of one hand at your belly button and while your abdomen is relaxed, gently press your fingertips into your abdomen.
- Lift the top of your shoulders off the floor into a “crunch” position.
- Feel for the right and left sides of your rectus abdominis and take note the number of fingers that fit into the gap.
- You will want to test this again approximately 1-2 inches above and below your belly button to determine the length of the gap.
If you find you have a DR, you will need to avoid the following activities as they can create further separation of the abdominal muscles:
- abdominal sit-ups
- oblique curls
- double leg lifts
- upper body twisting exercises
- exercises that include backbends over an exercise ball
- yoga postures that stretch the abs, such as “cow” pose and “up-dog” pose
- pilates exercises that require the head to be lifted off the floor
- lifting and carrying heavy objects
- intense coughing without abdominal support
Basically, you will need to avoid any exercise that causes your abdominal wall to bulge out upon exertion. Once the DR is closed, you can gradually add these activities back in.
Diastasis Recti Correction
In general, correcting a DR includes proper fitting for an abdominal brace if needed (we will discuss this later on), core stabilization exercises, postural training, education on proper mobility techniques, and proper lifting techniques.
In some cases, a self-guided program may be enough to correct a DR. But we recommend that postpartum women and post-surgical patients see a qualified pelvic floor PT if they believe they have a DR. Typically, DR patients also have other things going, and a pelvic floor PT will evaluate everything from the ribs down to the knees.
Here’s a complete rundown of what I do to repair a patient’s DR:
During the first visit, I assess the length and width of the separation, the strength of the patient’s transverse abdominis muscle, the motor control of the pelvic floor, and the patient’s posture. In addition, I assess hip, back, and sacral stability. Knowing a patient’s overall impairments is important in correcting a DR, because only then can we put together a proper treatment plan. Since every patient is different, treatment plans are specifically tailored for each patient.
So how do we get down to actually closing the DR?
Thankfully, closing a DR is not rocket science. The patient takes a towel or bed sheet, wraps it around his or her waist, and crosses it at the largest gap in the DR. For most people the largest gap is at the belly button. The patient must hold the sheet nice and tight, making sure the sheet is in between the ribs and hip bones as they can hinder the sheet from being as tight as it needs to be. In that position, the patient does mini-sit ups.
Patients need to do 30-60 DAILY repetitions for the DR to close. The purpose of the sheet/towel is to bind the muscles together while the sit-ups strengthen the muscles in the correct position, and close the gap. Doing sit-ups without a towel or sheet will cause the gap to widen.
In addition, I work to educate my patients on what activities/exercises to do and not to do. For example, I’ll tackle postural education, meaning I will show them how to sit and stand correctly, I’ll teach them how to best carry heavy items (although this should be avoided if at all possible), how to lift objects correctly, including baby for postpartum patients, and how to correctly get in/out of bed, among other things.
With a diastasis recti patient, once he or she has a good understanding of his/her home program and how to contract their abdominal and pelvic floor muscles correctly, I recommend PT frequency of once every two to four weeks, so that I can check their progress and progress their home program. Some patients require a full hour of treatment, while others only require 30 minutes.
I should mention here that more often than not, my patients with a DR have other impairments that also need treatment, usually pelvic floor muscle weakness.
But some patients also present with pain in addition to their DR. For these patients, I recommend weekly treatments in order to resolve the impairment that can be causing the pain, such as myofascial trigger points and/or hypertonic (too tight) muscles. Remember, DR causes pelvic instability and abdominal wall weakness, which in turn causes other muscles to compensate. This compensation can create muscle spasms and these muscle spasms can lead to joint misalignment and poor muscle function, which can create pain. For patients who also have pain, treatment typically consists of an hour-long appointment, once weekly for six to eight weeks.
As far as how long it takes for a DR to close, it all depends on how large the gap is, abdominal muscle strength, and other issues, such as obesity. The wider the gap, the longer rehabilitation will be. That said, although every patient is different, changes should start to occur within six weeks of rehab.
Some patients do require surgery to correct the DR if it is not closing. If you do not see a sufficient closure of the DR by 12 months with consistent rehab efforts, then a surgical repair may be necessary. A general surgeon or a plastic surgeon can perform the surgery.
To brace or not to brace
According to the social media/blogging world, every postpartum woman needs to wear a brace. This inaccurate messaging seems to go hand-in-hand with the incorrect claim that 90% of postpartum women have a DR, and it’s equally untrue.
Wearing a brace can result in a patient’s over-reliance on the brace reducing the opportunity to retrain the abdominal muscles.
That said, there are situations when a brace is necessary, especially if a patient can’t properly contract her abdominal muscles. For instance, if she can’t engage her Transverse Abdominus muscles (TrA) then she will compensate and use the Rectus Abdominus (RA). Incorrect usage of the RA will reinforce and even continue to split the DR. Once the patient can contract and use the TrA properly then I have her (or him as my male DR patients can have the same issue) stop using the brace to prevent over-reliance.
If you have any questions about diastasis recti correction, please leave them in the comment section below!
Malinda Wright, PT, MPT treats patients in our Los Gatos office.