Separated abdominal muscles, known as diastasis recti or DR, is a topic that concerns many new mothers and parents. You may wonder why you still look pregnant several months or even years after giving birth, why you feel bloated and why you feel ‘hollow’ in your core and can’t do many activities you used to be able to do with ease. Even lifting and holding your baby may cause excruciating back pain. To search for answers, you turn to the internet where you become even more confused by the plethora of contradictory information and fear-mongering, such as: only surgery can heal DR; you should only do ‘DR-safe’ exercises; avoid crunches and planks; focus on ‘closing the gap’, etc. This misinformation often leads people to avoid all movement for fear of making the situation worse.
The intention of this blog post series in two parts is to provide the facts based on the current best evidence on the subject, as well as some tips on how to start healing a diastasis.
Definition and Causes of Diastasis Recti
What exactly is DR and what causes it? Anyone can have diastasis recti. The word diastasis means ‘separation’, and diastasis recti is a separation of the two sections of the rectus abdominis muscle. Sustained pressure on the abdominal wall is the main cause of DR. Pregnancy is the most common cause of DR as pressure from the growing uterus pushes out on the linea alba, the connective tissue between these muscles, and on the whole abdominal wall. Visceral fat (fat around the internal organs in the abdomen), unproductive breathing patterns and ineffective posture and daily movement patterns will also put persistent pressure on the abdominal wall, often causing DR.
While many people think that a large baby, a small body frame, multiple gestation (twins or triplets) or cesarean section cause DR, this is not substantiated by research. Genetics are thought to play a part in determining whether or not the abdominal muscles will return to normal after birth, but that, too, hasn’t been researched.
Many people think that they did something wrong in pregnancy that caused DR and blame themselves for the situation. Hopefully this graphic (right) will assuage any self-judgment.
According to research by da Mota et al (Manual Therapy, 2015), 100% of people have DR around the 35th week of pregnancy. This is normal. The abdominal wall needs to stretch in order to provide space for the growing baby. While the abdominal muscles usually return to a normal state after birth, Jorun Bakken Sperstad et al (British Journal of Sports Medicine, 2016) found that the incidence of DR is 60% at 6 weeks postpartum, 45.4% at 6 months and 32.6% at 12 months postpartum.
When a person asks their doctor about DR at the 6 week check-up, they are often referred to a surgeon and the problem is considered cosmetic. Most people aren’t aiming to have a perfectly flat abdomen; they just don’t want to look pregnant. They might be embarrassed about being naked in front of their partner, affecting their relationship, or simply looking in the mirror, affecting their self-esteem in general.
What about function? Can you lift your head up off the bed? Can you pick up your child without experiencing back pain? Can you do the activities you used to love doing, like dancing, playing tennis or simply playing on the floor with your kids? Do you leak when you laugh or run? While the research isn’t conclusive about a connection between DR and urinary stress incontinence, one study by Spitznagle (Int. Urogynecol. J. Pelvic Floor Dysfunction, 2007) showed that 66% of women with DR in their 40’s and 50’s had some type of pelvic floor dysfunction.
While surgery is not possible until after a person has finished having children, many people are told that surgery is the only way to fix the problem. While surgery IS the only way to fix an umbilical hernia that often accompanies DR, it is usually only warranted for DR if someone is not able to generate tension in the linea alba, which remains soft and ‘distorted’ even when the abdominal muscles are activated. Most people don’t need surgery to heal diastasis.
How to Check Yourself for Diastasis Recti
You can perform a self check to see if you have DR.
- Lie on your back with your knees bent up towards the ceiling.
- Place your fingers horizontally at the navel and lift your head up as though you’re doing a small curl-up or crunch so that you will feel the muscles activating on both sides of your fingers. The higher you lift your head, the more the muscles will close around your fingers.
- The most accurate check is when the muscles are at rest, so lay your head back down and feel how many fingers you can fit horizontally between the muscles. This will indicate the IR (inter-recti) distance, commonly known as ‘the gap’. You want to check this in 3 places: at the navel, slightly below the navel and slightly above the navel.
- The gap is only one of the measures used to diagnose DR. Much more important than the width of the gap is the distortion or depth of the connective tissue, which should also be measured at those same three levels.
- It is also important to check how much tension you feel in the tissue beneath your fingers when you activate the muscles.
- All of the above is explained in this short video on how to check yourself for DR.
More Information on Diagnosing DR
Someone may have checked you and told you that you don’t have DR (a width of more than 2 cms. is the clinical definition of DR), while you are sure that you do have it, especially if you see the tell-tale sign of a pyramid-shaped dome in your midline between the rectus abdominis muscles when you lift your head up while lying down. In some people, the opposite happens: there is a marked indentation when they do this.
While using ultrasound to diagnose DR is considered the gold standard, very few clinicians (other than surgeons) use it and most simply use their fingers as described above. Research studies aren’t consistent about whether to check the IR distance on a curl-up or at rest. Some studies have been done with muscle activation and some have been done at rest. The higher you lift your head and shoulders, the more the RA muscles will close, so testing at rest solves the problem of discrepancy according to how high you curl up.
The Goal of Healing a Diastasis
While many people view closing the gap as the goal of healing a diastasis, the current thinking involves healing the whole abdominal wall rather than only focusing on the linea alba. The previous methods of wrapping a towel around the belly to splint the seam or wrapping the hands around the abdominal wall (techniques developed by Elizabeth Noble in 1976 and described in her groundbreaking book “Essential Exercises for the Childbearing Year”) are no longer recommended. Anatomically, when the broad abdominal muscles (obliques and transverse abdominis muscles) contract, they move away from the midline, i.e. the gap actually gets wider, which is why splinting the seam was originally recommended. However, according to more recent research by Diane Lee and others, rather than focusing on closing the gap, it is important to pick up the slack in the connective tissue. When there is more tension in the tissue, it can transfer loads through it, meaning that we can challenge it to stay taught and do harder exercises. Activating all the abdominal muscles in unison will keep the connective tissue taught and will stimulate it to strengthen and regenerate, while also strengthening the muscles. Contrary to popular belief, healing DR is NOT about closing the gap. You can have a wide gap and a flat belly, or a protruding belly and a narrow gap, or anything in between.
A Note About Pushing and Diastasis
Many people who are told during pregnancy that they have a diastasis worry that they won’t be able to birth their baby due to weak abdominal muscles. This is not supported by research and, remember, all pregnant people have DR in the third trimester. While pushing in the supine or lithotomy position has been shown to increase a diastasis, pushing in an upright position will use gravity rather than excessive intra-abdominal force.
Please look out for next week’s blog post when we will look at how to heal your diastasis recti and improve the strength and function of your whole core.
About Rachelle Oseran
Rachelle Oseran, BA, LCCE, FACCE, CD(DONA), ACE, has been actively teaching childbirth classes since she was certified in 1984 and is a Lamaze-accredited childbirth educator trainer. She also teaches Mindfulness Based Childbirth and Parenting. She is a fitness professional certified by ACE (the American Council on Exercise) and, for the past 36 years, has been teaching pre/postnatal fitness, helping women and men heal from diastasis recti and has lectured and given professional workshops on the subject in the US, Europe and Asia. She combined her extensive fitness experience with her certifications as a Yoga and Pilates instructor to create the online course, IMPROVING CORE FUNCTION, a systematic, effective and affordable program for healing diastasis recti. She is passionate about helping people heal their diastasis recti and gaining confidence in their bodies so they can return to the activities that they love.
She lives in Jerusalem, Israel, with her husband. They have 3 sons, 3 daughters-in-law and 4 grandchildren (so far).
Follow Rachelle on Facebook, Facebook group for healing DR, Instagram, and YouTube.
Author photo credit: Dani Sarusi Photography
Cover photo credit: Free stock photos by Vecteezy
TagsPostpartum Body Postpartum Care Postpartum Health Diastasis recti Postpartum Healing