Alright friends, it’s time to talk about the buzz topic: diastasis recti, diastasis rectus abdominis, DRA - all one in the same! DRA is definitely more widely discussed online as it pertains to the pregnant and postpartum periods. There is also quite a bit of misinformation around what it is and how to address it. We have seen many women in the clinic who are terrified by their separation and think they will feel weak in the core forever. Is that true? NO. Men, children and women who have never had children can also have DRA (looking at you, bad lifting mechanics and chronic constipation!) but for the purpose of this blog we are focusing on pregnancy and postpartum rehabilitation as it relates to DRA. Let's dive in!
1) What is it?
Diastasis Recti is the term given to the separation of your rectus abdominis muscles, or what we think of as the 6-pack ab muscles. As those muscles move laterally, connective tissue called your linea alba is also put on stretch. While many assume the rectus muscles are our main core muscles, there are actually 4 layers of muscles in the anterior abdominal wall. The linea alba is the midway point where all of your abdominal wall muscles come together. When this connective tissue is put on stretch, it can cause a doming or sinking in appearance of your abdominal tissue when you put load through it, as is the case when sitting up out of bed or curling up to get off the ground.
It’s also important to address what Diastasis Recti is NOT. DR is NOT a hernia. A true hernia is a break in the tissue which allows intestinal contents to push through the abdominal wall, whereas DRA is a thinning and stretching of the tissue. A hernia requires an ultrasound to diagnose and surgery to correct. Many people assume the doming or separation they see is a hernia, when in reality it is a diastasis.
2) Almost 100% of women will have one by the time of delivery
DRA is a normal part of a woman’s body preparing for birth. As the baby and uterus grows, the abdominal wall stretches to make room for that growth. Stretching of the tissue will cause the core muscles to be pushed laterally. Oftentimes, these changes will cause the fascia in the low back and side body to become tight and restricted. On the prenatal side, we like to encourage side bending and low back stretching to accommodate these changes in tissue and body alignment.
3) You can protect it.
While we know the majority of women will have DRA by the end of their pregnancy, that doesn’t mean we shouldn’t do our part to protect the tissue. Part of what we teach in prenatal appointments is how to be mindful of movement patterns that will make a diastasis worse.
Anything you are doing which causes a doming of the abdominal wall during pregnancy should be modified. For example, coming on to your side before sitting up out of bed is a huge one (AKA log rolling). In Dr. Katie's experience, she started doming around 16 weeks pregnant with her first child. This was well before her belly was that big, but she started getting out of bed on her side, as if she was already 36 weeks pregnant, to decrease the strain. Any core exercises that cause doming should be regressed to be made easier or eliminated from your regimen. At the end of the day, DRA is a pressure management dysfunction, so where can we find an appropriate challenge that is successful and safe?
Another great way to protect the tissue is to focus on your breath and core engagement together. You want to focus on creating a muscular brace to protect the tissue whenever you are under load. Load could be as simple as coughing or yelling, or as complex as deadlifting or picking up a toddler off the ground. By drawing up and in of your abdominal wall and a slight lift of the pelvic floor, you are protecting the vulnerable tissue from excessive pressure that could worsen a separation.
4) Soft tissue work can help.
On the postpartum side, we will diagnose a diastasis recti by asking the patient to lift their head off the table to engage through the abdominal wall. When she does this, we use our fingers to assess the width and depth of the separation from the top of the abdominal wall to the bottom. Considering more recent research and hormonal as well as normal tissue healing process, I prefer to wait until the 8 week postpartum mark for true assessment.
As pelvic floor therapists, we spend a lot of time on abdominal massage in the early postpartum days. This work helps to reduce the lateral tightness which can cause pulling on the rectus muscles. There are occasionally trigger points throughout the rectus muscles which can keep the fascia tight and separated. Oftentimes, we can see changes in the width of the tissue within a session or two of freeing up fascial restrictions. However, it is important to note studies have found the width of the separation is not correlated to function. This means a woman could have a 3 finger separation but have no pain or functional limitation if she learns how to generate tension properly to protect her core. That leads us in to the 5th thing to know about diastasis recti.
5) It NEEDS to be loaded.
Protecting your core during this time of change is important, but is often stressed to the point of fearing movement at all, which is also a mistake. Just like strengthening in any other part of the body, the core muscles need to be loaded properly to stay strong and also heal on the postpartum side. It may just look different than traditional exercises you have previously seen or done.
One of the best ways to maintain core coordination and function during pregnancy is through diaphragmatic breathing and functional movements like squats and deadlifts with a braced core. Some examples of core exercises we have prescribed to women during pregnancy or healing diastasis include farmer’s carries, planks (modified as necessary with a good brace - side note, lateral planks are a great bang for your buck in the early phases to engage core and protect the low back), and unilateral weighed squats, marches, presses, etc. Holding weight in one hand vs two allows for cross activation of the core which can help minimize the separation and strengthen both sides of the core at the same time.
6) Most recover fine without surgery.
Education is SO important. Because talk of diastasis recti has exploded over social media and the internet at large, several women have come in to the clinic and think they are broken or they need to have their separation surgically corrected. As long as she learns to generate tension across the core well to support the spine, there will be no need for surgery. In some rare instances, there is a true break, or hernia, of the tissue that needs correction. There are also some infrequent cases of women having such a wide or deep separation that it makes the ability to generate tension very difficult. If you are concerned, we HIGHLY suggest seeing a pelvic floor therapist and starting a rehab protocol before considering surgery.
We hope you have gained some insight into the topic of diastasis recti. To recap, if you have given birth, it is likely you had a diastasis at some point. There is a good chance it went away on its own if you haven’t had symptoms. If you notice doming through the abdominal wall, you want to make sure you are protecting the tissue by getting up on your side and bracing under load. You can also reach out to a pelvic therapist in your area to address any soft tissue work needed and guidance on core progressions. Whether your child is 8 weeks old or 18 years old, it is never too late to get a consultation if you are wondering what’s going on in your core.
Health & Happiness,
Dr. Carly and Dr. Katie