Diastasis Recti

WHAT IS DIASTASIS RECTI?

Diastasis Recti is a separation in the linea alba, which is the center line of your six pack muscles. This leaves the left and right side of your abs looking and feeling "separated". DR has also been referred to a "mommy tummy" because of a pooch or flabby belly appearance. A mom with DR could be trying to lose their stubborn baby fat for years without success because they may not recognize the problem is DR. A mom with DR is not comfortable with their side profile appearance. A mom with DR may like to wear spanx or a belly compression. A mom with DR might have been asked “when is your baby due?” by a stranger, even though they are not pregnant.

Diastasis Recti is usually "painless" but this dysfunction can causes other problems/pains. The separation compromises the integrity of the abdominal wall and is linked to low back pain and urinary incontinence. It is reported that 32.6% of women have DR at 12 months postpartum. (Sperstad, 2016) We can help reduce this number with some education.

illustration01-2.jpg

TO CHECK YOURSELF FOR DIASTASIS RECTI:

  • Lie on your back and place your fingers in the center of your belly just above the belly button.

  • Slowly lift your head until your shoulder blades are off the bed, while feeling how many fingers you can insert between the belly muscles.

  • Put your head back down and place your fingers in the center of your belly just below the belly button.

  • Slowly lift your head until your shoulder blades are off the bed, while feeling how many fingers you can insert between the belly muscles.

  • If you have a separation you will feel your fingers sink into the abdominal cavity. Your fingers will go past the abdominal muscles, which are like a shelf.

  • If there is no separation (no DR) when you hit the linea alba it feels like a trampoline.

IMG_0934.jpg
IMG_0933.jpg

WHAT MAKES YOU AT RISK?

Several factors have been identified as a causal relationship for DR in pregnant women:

·       Older women (older than 33 years)

·       Multiple Children (2 out of 3 mamas have it after 2+ babies) 

·       Carrying a larger baby (>8.01 lbs)

·       Greater weight gain ( >35 lbs)

·       Birth by cesarean section

WHAT CAUSES IT?

It is easy to blame the factors above for "causing" diastasic recti, when in reality they don't usually CAUSE it. DR is a problem of excessive intra abdominal pressure- meaning that poor posture/alignment and using the wrong core muscles at the wrong time places excessive pressures on the abdominal wall. Think of your core as a water balloon. The proper amount of pressure is good, just like when you fill a water balloon with the perfect amount of water. Too much pressure, however, is bad, like when you overfill a water ballon and it bursts. When your abdomen experiences too much pressure, something has to give, so with DR the linea alba separates. Excess pressure in the abdomen can also cause other problems such as urinary incontinence and pelvic organ prolapse. When loading your system you need to make sure that your core is able to handle the load, and that you are loading it in the correct positions. If not this can cause a disruption to the system as a whole. 

During pregnancy it is normal to have some separation of the the linea alba, but it should fix quickly postpartum. Doing the wrong exercises during pregnancy can worsen the separation and lengthen your recovery time.

Being over zealous with your postpartum exercise routine can leave you exposed to years of problems. It is imperative that you heal correctly and it is never too late for this. I know because I have worked on DR patients in the clinic who have 40 year old children. 

WHAT DO I NEED TO DO TO CORRECT THIS?

My goal is to coach you and educate you about DR because there is a lot of misinformation out there. Please take advice from me as a physical therapist because the recovery is complex. I want you to know that the guides are written to avoid and heal DR. That being said, I do not think exercise is the ONLY thing you need to do to fix it. Healing DR also requires a change in your habits, gaining some body awareness, and in many cases may require individual expert attention. Fixing this problem often takes persistent hard work over a period of time. Below are KEY components of healing DR.

IMG_0965.jpg
  1. Proper core strengthening

  2. Strengthening other areas you would think would have NO impact on your abdominal separation.

  3. Diaphragmatic breathing

  4. Pooping properly

  5. Reducing daily intra abdominal pressure

  6. Posture

  7. Avoiding “doming” of the abdomen with activities (see picture at right)

  8. Reducing rotational movements (especially loaded)

Proper Core Strengthening

BENEFITS OF EXERCISE

Women who engaged in a regular exercise program prior to pregnancy DID NOT experience DR as frequently as those that did not. Thus possibly indicating a correlation between having a strong core and preventing DR.

When restrengthening the core, you want to work on it from the inside out. It is like building a home: having a good foundation is imperative to having a strong home. Remember “core strength” is comprised of abdominal, back, diaphragm and pelvic floor strength. NOT just abdominals. 

CAN YOU EXERCISE IF YOU ALREADY HAVE DR?

Not exercising is the worst possible thing you can do for minimizing DR during pregnancy and postpartum. Exercise is important but proper exercise means taking extra precautions to protect yourself from making the gap worse and/or change the workout patterns that caused the problem in the first place.  

At the bottom of this post you can enter your email for a printable freebie of exercises you should be doing if you are experiencing DR. If you already have either of the guides, keep doing them and add these extra exercises. The guide is THE BEST at helping you heal this problem so it is worth the investment if you don’t have it.

TRANSVERSE ABDOMINALS

Your transverse abdominis has fibers that connect into the linea alba. This is a deep muscle that lies behind the rectus abdominis (the layer of abdominals that is affected by DR). The transverse abdominis is a very strong muscle because it has cross-fibers that run diagonally like a Chinese finger trap.

To locate this muscle, place your fingers on the inside of your pelvis, then go one inch in and one inch down from the pointy parts of the hip bone. To activate this muscle, imagine the two sides of the hip bones pulling together as if you are generating tension like a gentle hug.

This muscle can be difficult to wake up so if you are having trouble activating it, be patient. It just takes practice.

PELVIC FLOOR

Your pelvic floor should be the first muscle to turn on when you make a move, followed shortly by your transverse abdominals. These two structures are very linked. Think of them as best buddies. If one is functioning well it really helps out the other one. However if one is in bad shape, it can be damaging to the other one. A study by Tracy Spitstegal showed that 66% of women with DR had a pelvic floor dysfunction at age 50. So women who have DR may not be displacing dysfunction in their pelvic floor early on, which causes issues later in life after the pelvic floor has taken excessive pressure for so long. The better you can control pressure, the better you are able to support your holes.

How to perform a Kegel

Your pelvic floor is a diamond shape, so when turning on your pelvic floor you want to do this from back to front and side to side. The best cues to do so are thinking about your pelvic floor being like a “claw” on one of those stuffed animal games. Drawing in all 4 sides of the pelvic floor as if the claw is lifting up into your vagina. Other cues that work is nodding the clitoris downward as you pull your rectum towards the back of your pubic bone.

Strengthening other areas

When thinking about healing DR, there are many areas that we need to pay attention to besides your core. The following areas typically can place excessive pressure on your abdominal wall if they are weak or tight. These areas are often affected by pregnancy and do not automatically function normally postpartum. Below are some exercises to assess these areas. This is where an individual assessment by a physical therapist can be helpful because often it is not just one area that is disrupted with DR; it is usually a break down of your kinetic chain.

LATISSIMUS DORSI

Stretch: place your elbows on a chair or table. Put your hands together if you are praying with your fingers upward. Drop your chest down towards the floor as if there is an anchor attached to your chest.

Strengthen: Anchor a resistance band in the top of a doorway. Start in an upright position holding the ends of a resistance band in each hand that with your arms straight. Pull down against the resistance band bending your elbows as you bring them to shoulder level. Make sure to keep your back straight, maintain your balance and think of squeezing your shoulder blades together as you pull your arms back. Slowly return to starting position. Repeat for two sets of 20 repetitions.

HAMSTRINGS

Stretch: Foam Roll out your hamstrings. Place the foam roller behind your knee and work upwards towards your hips. Finding areas of tension, hold that spot or slowly isolate back and forth over that spot.

Strengthen: If you have a chair that rolls at home you can sit on the edge of it and dig your heels into the ground while pulling yourself across the room with your heels.

Strength Option 2: Use a stability ball. Lay on the ground on your back and dig your heels into the ball, lift your butt and pull the ball towards your bottom bending your knees (make sure there is NO doming).

LATERAL HIP

Stretch: Using a lacrosse ball, cross your leg over on the opposite knee. Place the lacrosse ball in the meaty part of the butt and roll on your sore spots of the hip. (As a mom this maybe sore so you can offload your butt from the ball by pushing through your arms.)

Strengthen: Start by lying on your side. Bend your bottom leg, but keep it on the floor. Your top leg is straight. Slowly lift your upper leg toward the ceiling. Your top leg will only lift 6” from neutral. Do not lift it high! Lower it back to the starting position. Keep your hip, knee, and ankle in one line. Do not allow your hips to roll backward or forward during the exercise. You should feel a deep burn in the hip. Repeat 30 repetitions on each leg.

FEET

Stretch: Yoga Toes are great for this. Also placing your fingers between your toes and pulling the foot upward and downward.

Strengthen: Loop a resistance band around your forefoot. Point your toe upwards you and then draw your big toe in toward your midline as you point your foot downward.

Diaphragmatic Breathing

Breathing is very therapeutic to healing postpartum. During pregnancy our diaphragms are smashed by the baby and our pistoning system is not fluid. We need to re-expand our diaphragm. Deep breathing also helps to keep us calm which in an important skill in mothering due to the correlation with the vagus nerve.

Proper Diaphragmatic Breath

  • Think of your lower ribs as a handle on a sand bucket. The ribs attach in the front and the back sides. The diaphragm is below the lower ribs and our breath creates movement in the ribs. Your ribs should expand out to the side and forward and backward.

  • Try placing your hands on the lower ribs to assist you to recognize to draw into this area.

  • When your diaphragm is expanding with your breath it is an umbrella.

  • You don’t want to emphasize breathing into your belly. You want a nice breath without excessive pressure in the belly.

See the YouTube videos below to see proper breathing patterns.

Proper Pooping

Your setup on the toilet is the first step. Ideally you want to be an in squat position. Many other cultures do not have such high toilets as we do. Your knees should be higher than your pelvis. To achieve this, you can use a squatty potty or tip a garbage can on its side.

Perform the double E’s. Exhale while you evacuate. You can exhale or make a grunting sound this helps allow your rectum to relax.

Relax on the toilet. We are so often busy bodies, but he toilet should be a place to rest and not play on your phone. Sit down and focus on pooping.

Massaging your sacrum downward can help stimulate your nerves to relax. Start at the top of your hips and use your fingers, massaging downward in circles to get things moving.

Reducing Daily Intra-Abdominal Pressure

There are daily activities that we perform that increase our abdominal pressure that we don’t even realize. If we don’t know how to control that abdominal pressure, it places excessive pressure on our abdominal wall. Just as if you have a scab that you keep picking at the scab can never heal. If you figure out how to stop placing pressures on the abdominal wall, then it will allow it time to heal.

Here are a couple of every day things that may increase our intra-abdominal pressure. Getting out of bed, lifting toddlers, lifting carseats and other heavy items such as groceries. If you have DR it is important to be conscious of this and alter the way you move, and/or use your pisitoning system as you move to help decrease the pressures that go through our abdominal area. This is as simple as exhaling as you perform the “difficult or effort” piece of the movement. You can also try the movement a different way. Look to decrease doming or holding your breath to perform tasks. Avoid returning to exercises too quickly postpartum that your body is not ready for.

Posture

POSTURAL ASSESSMENT

During pregnancy and postpartum, if we don't have appropriate strength we will just "fall into" poor postural positions. Slouching is one of the worst things you can do for DR. But you also do not want to hold your muscles (abs or butt) tight all the time to achieve proper posture. The key is to have the front of your ribs in line with your pelvis. To check this, put your fingers into a cowabunga sign (three middle fingers tucked in, pinky and thumb out) and place your thumb on your lower ribs and pinky on the front part of the pelvis. Your fingers should be on the same plane. If they are not. get tall as if some one is pulling your hair through the crown of your head (ponytail). This creates space then bring your ribs back or forward to line up with your pelvis.

Sitting: It is very easy to fall into a slumped posture when sitting. The slumped posture places more stress on a DR. While sitting in the car you can try lengthening one side by pushing one butt cheek into the chair and pushing your ribs outwardly while you think about lengthening your sides. Sit with your butt all the way back on the back support with feet on the floor.

Sitting Less: Try some of these options:

  • Getting a standing desk at work

  • Eating meals standing

  • Lie on the floor while watching TV and stretch

  • Walking instead of driving

Hanging

When healing DR, the focus is not only on the abdominals. Hanging can assist in rib mobility, stretching the thoracodorsal lumbar fascia and helps to traction the spine. Holding with both hands, drop your knees out from under you and make sure to keep your elbows straight. I do this at the park ALL the time with the girls. I try to lengthen one side as if I am reaching downward with one foot while taking diaphragmatic breaths. You can gently twist on the bar with your torso. I would not do this excessively but small rotations can help.

Avoiding Doming

Doming is a tent like appearance your abdominal wall displays when there is too much intra-abdominal pressure. Pressure in the abdomen should be like Goldilocks and the three bears: The pressure should not be “too much”, not “too little” but just right. Doming is seen in both exercise and everyday life. If you see doming, stop the activity. You often see this while working out during pregnancy and postpartum, or performing activities that are “too tough” for you yet. That is why proper activity is important. Exercises that you tend to see this with and therefore should avoid if you can’t control the pressure or have DR are planks, crunches, russian twists, rope slams, lifting excessively heavy weight.

Avoiding Rotational Movements

When you have DR there is a large space from one side to the other of your abdominals. When you try to do activities that involve crossing your body this is typically unsuccessful because you are missing the ability to transfer forces from side to side due to your abdominals being split. Avoid any loaded rotation until your abdominal wall is intact. This could mean taking extra steps. If you move your feet you can move so that you don’t have to rotate on top of a stable structure. For example, putting the dishes away.

Exercises to avoid: Russian twists, med ball slams side to side, weighted chops.

OTHER THOUGHTS

AVOIDING DR DURING PREGNANCY

Due to the over-stretching caused by a growing fetus and soft tissue laxity caused by hormonal changes, the linea alba can split. One study reported that the incidence of DR is 66% in the third trimester (Boissonnault, 1988.) YIKES! That is a large percentage. 

Planks, sit-ups, crunches, or anything that places excessive pressure on your expanding abdominal muscles should NOT be performed after 20 weeks of pregnancy. Women with DR have difficulty with weight transfer from side to side due to the split in the abdominal wall. During exercise this also makes it difficult to do diagonal movement, such as oblique work. Sports that require a lot of rotation, such as tennis, soccer, and kayaking, can also worsen the DR or minimize healing.  

FINDING ADDITIONAL HELP

If you find that your DR is not healing, there are great Womens health therapists out there to help you fix that gap! Soft tissue mobilization can be a big part of restoring your core because a PT can help get restricted tissue moving so that it functions best. You can do this by using the Women’s Health PT Locator at http://www.womenshealthapta.org/pt-locator/. Click on pregnancy/postpartum for speciality and call and ask if the therpsit works on DR patients!

OTHER INTERESTING FACTS

It is common for pre and postnatal women but it also affects women that never have had any children. Men can have it too. 

REMINDER

As humans, we are often looking for a quick fix and unfortunately there just is not one when it comes to DR. Staying consistent with programming is one of the best things you can do prior to healing. 

Sources: 

Boissonnault JS, Blaschak MJ. Incidence of diastasic recti abdominis during the childbearing years. Phys Ther 1988;68(7):1082-1086.

Noble E. Essential Exercises During the Childbearing Year. 4th ed. Boston: Houghton-Mifflin; 1996.

Hannaford R, Tozer J. An investigation of the incidence, degree and possible predisposing factors of diastasic rectus in the immediate postpartum period. J Natl Obstet Gynecol Special Group of the Australian Physiotherapy Association 1985;4:29-32.   

Polden M, Mantle J. Physiotherapy in Obstetrics and Gynecology. Oxford: Buttrworth Heinemann; 1990.

Grab Your Diastasis Recti Freebie!

* indicates required
Krystle Howald