Diastasis rectus abdominis or Diastasis Recti

by Amy Seczek
Registered Physiotherapist  MScPT
updated Mar 2, 2023

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What is diastasis rectus abdominis?

Diastasis rectus abdominis (DRA) refers to the separation of the two rectus abdominis muscles (the six-pack muscles) and change in integrity of the linea alba. The linea alba is the connective tissue connecting both sides of this muscle at the midline of the abdomen. DRA occurs due to increased pressure in the abdominal cavity. This happens most commonly during pregnancy, but can also happen with increased abdominal girth due to obesity, swelling, etc. 

As the baby grows during pregnancy, the increased pressure in the abdomen pushes on the linea alba. The tissues of the linea alba adapt to this load and stretch. As the linea alba stretches, this creates a separation between the muscles. After delivery, the separation will usually close back up. 33% of women will exhibit DRA during the second trimester, and 100% will experience DRA by the end of pregnancy. Up to 60% of people experience DRA at 6 weeks postpartum. 

Refer here for our guidance during the first 6 weeks postpartum: https://cornerstonephysio.com/resources/postpartum-guide/ 

The diastasis can occur at different levels of the linea alba (closer to the top, bottom, or all throughout it).

Types of Diastasis Recti

You are at higher risk for developing diastais rectus abdominis if you have a higher body mass index or have diabetes, and the risk also increases with each pregnancy as strain is repeatedly placed on the linea alba (Wu et al., 2021).

 

What is a Hernia vs. Diastasis Recti?

Rather than stretched connective tissue, a hernia is an actual hole within the tissue. We all have an umbilical hernia (belly button) which is the hole where the umbilical cord originates as a fetus. It is generally small enough so that the intestines could not protrude, however if the hole becomes bigger this can potentially lead to an umbilical hernia. This will usually require surgery as it is a irreversible hole/defect in the tissue rather than stretched tissue which could gradually close.

 

How do I know if I have diastasis rectus abdominis?

In order to be sure, it is best to be assessed by your doctor or pelvic floor physiotherapist. Symptoms of diastasis recti may include:

• Feeling a deep gap between your “six-pack” muscles
• Coning or doming of the abdomen when doing sit-ups or other core exercises
• Low back pain or pelvic girdle pain
• Weakness of your core muscles

Your pelvic floor physiotherapist will assess the degree of your DRA by determining your ability to create tension in the linea alba and its depth and width during muscle activation and functional activities. They may also determine your pelvic floor function through digital examination (i.e. internal pelvic examination).

Traditionally, Diastasis Rectus Abdominis has been diagnosed when there is a two finger width distance between the two sides of the rectus abdominis muscles. However, this is not a reliable method as fingers are not all the same size. Depth is also an important consideration and the ability to produce tension in the rectus abdominis muscle during exercises helps to dose exercise prescriptions appropriately. Ideally, exercises should be difficult enough to build strength and see changes while also managing pressure.

Refer to this article for more information about your initial pelvic floor physiotherapy assessment: https://cornerstonephysio.com/resources/how-does-pelvic-physiotherapy-work/

 

Can I prevent diastasis rectus abdominis from happening?

The evidence is not entirely clear for why DRA happens. In fact it may be partly due to your genetic makeup. To reduce the incidence of diastasis recti and speed recovery postpartum, you should:

• See a pelvic floor physiotherapist to ensure you are performing core and pelvic floor  exercises adequately and correctly
• Continue to maintain a strong and healthy core
• Avoid excessive weight gain during pregnancy
• Avoid excessive straining during a bowel movement

Here are useful recommendations for the different periods of pregnancy and DRA prevention (Dufour, S. 2019)

Prenatal

1. Emphasize neutral postures that reduce pressure inside your abdomen
2. Modify habitual movements to reduce repetitive intra-abdominal pressure increases (e.g. try rolling to get up from bed instead of sitting up)
3. First perform exercises to activate your inner core unit (pelvic floor and transverse abdominis), then progress to engaging your outer core unit (6 pack muscles, obliques) while performing functional movements
4. Avoid exercises that contract the superficial abdominal muscles such as sit-ups
5. Emphasize a deep/diaphragmatic breathing pattern

During labour and delivery

1. Prioritize mobility during labour
2. Avoid pushing with a closed glottis (e.g. try to blow as you go)
3. Birth in positions where the sacrum at the bottom of your spine is free, rather than lying on your back
4. Encourage practices to reduce the likelihood of operative birth

Early postpartum

1. Emphasize neutral postures that reduce intra-abdominal pressure
2. Modify habitual movements to reduce repetitive intra-abdominal pressure increases (e.g. try rolling to get up from bed instead of sitting up)
3. Avoid exercises that contract the superficial abdominal muscles such as sit-ups
4. Emphasize a deep/diaphragmatic breathing pattern
5. Perform exercises to activate the inner core unit, then progress to engaging the outer core unit within functional movements
6. Avoid high impact exercise
7. Avoid exercises that result in incontinence

Late postpartum

1. Emphasize neutral postures that reduce intra-abdominal pressure
2. Emphasize a deep/diaphragmatic breathing pattern
3. Encourage optimal body positioning for everyday tasks (e.g. carrying your baby)
4. Modify habitual movements to reduce repetitive intra-abdominal pressure increases (e.g. try rolling to get up from bed instead of sitting up)
5. Perform exercises to activate the inner core unit, then progress to engaging the outer core unit in functional movements
6. Modify exercises that cause doming of the linea alba
7. Cautiously approach exercises that contract the superficial abdominal muscles such as sit-ups
8. Address impairments in pelvic and thoracic (middle to upper back) movement
9. Cautiously approach exercises that result in incontinence

 

Can diastasis rectus abdominis fully recover?

In most individuals, DRA will gradually close after childbirth. In some individuals, this will not happen on its own. However, improving the strength of your core muscles and their overall functioning can greatly reduce symptoms.

 

What is the treatment for diastasis rectus abdominis?

Pelvic floor physiotherapy

The inner core is made up of the diaphragm at the top, the pelvic floor muscles at the bottom, and the transverse abdominis wrapping around the abdomen.

The transverse abdominis is an important muscle to activate to assist in closing the gap.

• Week 1-6 postpartum basic core program https://z2c5s8c4.rocketcdn.me/wp-content/uploads/2022/10/Cornerstone-Pelvic-Health-Postpartum-Week-1-6-basic-core-program.pdf

A trained pelvic floor physiotherapist will assess the extent of your DRA and determine the best course of treatment. The assessment will include an external and internal examination to assess the function and strength of your pelvic floor and core muscles.

Exercises will involve strengthening the inner core along with the pelvic floor muscles to assist in closing the gap, along with function-based exercises to help you move better without pain or discomfort.

Lifestyle changes

Part of the burden of Diastasis Recti can be aesthetic in nature. In order to target the aesthetic component, consider lifestyle changes: consuming a healthy diet, moving your body (150 minutes of moderate to vigorous activity per week), sleeping well, and managing stress. The abdominal skin is stretched during pregnancy and it is important to understand that skin will not return to its original condition.

Abdominal braces

There is a lack of evidence to show that abdominal bracing should be used as a corrective technique, and in fact, it may even put you at greater risk of pelvic organ prolapse: https://cornerstonephysio.com/resources/what-is-prolapse/

Consult with your pelvic floor physiotherapist for advice about your specific case.

Surgery

Surgery should only be considered when up to 1.5 years of conservative management and treatment has been considered. If your DRA is severe and conservative management is not successful, you may be referred for surgery to repair the linea alba. This is more likely if you are experiencing a hernia. There are different options available for surgery and it is best to consult with your surgeon and pelvic floor physiotherapist to determine what is the best option for you.

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If you are experiencing problems with diastasis rectus abdominis we have rehabilitation experts that can help. Our pelvic floor physiotherapists are found at Cornerstone Physiotherapy locations throughout the Greater Toronto Area. Contact us today, and get us on your team!

 

 

References 

Dufour, S., Bernard, S., Murray-Davis, B., Graham, N. (2019). Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: a delphi consensus study.  Journal of women’s health physical therapy. DOI: 10.1097/JWH.0000000000000130

Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British journal of sports medicine, 50(17), 1092–1096. https://doi.org/10.1136/bjsports-2016-096065

Wu, L., Gu, Y., Gu, Y., Wang, Y., Lu, X., Zhu, C., Lu, Z., & Xu, H. (2021). Diastasis recti abdominis in adult women based on abdominal computed tomography imaging: Prevalence, risk factors and its impact on life. Journal of clinical nursing, 30(3-4), 518–527. https://doi.org/10.1111/jocn.15568