Diastasis Recti is a topic I have been wanting to write about for a very long time now because it can have such a huge impact on the lives of so many women I treat.
However, I have felt that my personal understanding of the condition needed to continue evolving to be able to present a more helpful and comprehensive dialogue for those who may be searching to find answers for themselves or their patients.
Our current culture seems to place a HUGE amount of undue pressure on women to regain their pre-baby body, fast. Without understanding the potential impacts, many new mamas are returning to traditional fitness and 'core strengthening' exercises (including running, crunches, sit-ups and planks) before their bodies are ready. Unfortunately this can increase the risk of pelvic floor dysfunction (including prolapse and incontinence) and actually worsen abdominal separation. Getting the 'all clear' from your GP at your 6 week check up does NOT mean you can immediately return to all physical activity. In fact, the hormonal effects of pregnancy alone can last up to 12 months postpartum (or until you are finished breastfeeding), which means the body is less able to handle increased physical stress at this time.
What I find is often missing from discussions of Diastasis Recti (DR) is the emotional impact that this later diagnosis can have for a lot of women - whether it is related loss of confidence in their body image, grief at no longer being able to perform the activities they love, feeling ‘broken’, frustration at being misdiagnosed for so long, or the slow healing process (a similar pattern for all pelvic floor issues that I've seen). For anyone experiencing these DR-related impacts, please know that you are definitely NOT alone in these feelings. And also that your tummy does not define you. Not now, not ever.
I hope that this blog gives you a bit more insight into the whole-body perspective of this very common condition so you can start moving forward in your personal journey to healing.
What is it?
Diastasis Recti refers to the unnatural separation of the abdominal muscles via stretching or thinning of the connective tissue in the midline (Linea Alba). While this is very normal to occur during pregnancy to allow for a growing baby (100% of women will have some separation at 37 weeks gestation), it is when the muscles remain apart after baby is born that this can become a concern. A distance of 1-1.5 finger widths between the muscle bellies is considered “normal” and greater than this would be considered a diastasis, however the prognosis of healing will be affected not just by the distance of separation, but also the amount of tension remaining in the linea alba.
Image from www.mutusystem.com
*Just to be clear, even though DR is often referred to as a ‘separation’, this does not mean that there is an opening in the abdominal wall, rather that the muscle bellies are sitting a bit further apart. There is still intact connective tissue between the muscles, however it may be thinner than before - unlike an hernia which refers to an actual tear or hole in the connective tissue.*
The most common symptoms of Diastasis Recti are the appearance of a belly bulge, a feeling of core ‘weakness’, and compromised function of the deep core and pelvic floor muscles (which stabilize the pelvis and the spine) leading to hip, pelvic, and back pain or pelvic floor issues.
However, Diastasis Recti is not always visible or symptomatic. For example, I have known some women with 4cm separations postpartum to have a ‘flat’ stomach (as defined by societal expectations), be pain-free and still be able to perform very physically strong feats. Therefore, I don’t believe the end goal of healing is just about the width of separation, but how all of the muscles in the body function as a whole.
Lets start with a short anatomy lesson! You have four layers of abdominal muscles:
Rectus abdominus (10 on the diagram)- colloquially referred to as your ‘six pack muscles’, these are the most superficial (closest to the surface of the body) and run top to bottom.
External obliques (11) - these are more of a diagonal orientation
Internal obliques (12) - on the opposing diagonal to the External obliques
Transversalis abdominus (13) - the darling of physiotherapy and the Pilates world, which is often referred to as your TA, TrA or TVA and is considered to form the deep stabilizing core layer.
(Illustration by Peter Bachin)
Most muscles in the body attach (via fascia or tendon) to a solid bony structure which allows them to be able to generate force or movement. However, we don’t have any bones at the front of the abdomen, so instead, the abdominal muscles overlap via layers of fascia and connective tissue (9) to form a thicker midline structure - the Linea Alba or LA (25) - which runs from your breast bone (the xyphoid process) to your pubic bone, providing a strong lever from which these muscles can generate force to move or stabilize the spine and abdominal contents.
What causes it?
While DR is usually thought of as only associated with pregnancy, abdominal separation can occur in women who have never been pregnant, and even men. Recently I’ve encountered three men - all fairly young and fit, in their mid 20s to late 30s - with 3 finger-width separation of their abdominal muscles and varying levels of firmness of the fascia. Including my husband! (Don’t tell him I told you).
This is due to forces that pull the muscles apart via muscle tension or positioning, or push it out and stretch the fascia from the inside due to increased pressure inside the abdomen (intra-abdominal pressure / IAP). Including:
Over-corrected sitting and standing posture - a habit of thrusting the ribs with chest out, shoulders back. Although we are often taught is a good posture - this actually creates excessive tension on the linea alba - pulling it apart - AND generates more IAP!
Very tight abdominal musculature - which can increase IAP and also pull away (think tight oblique muscles pulling on a diagonal away from the midline)
Shortened psoas major - this will often appear as rib thrusting when lying down on your back with the legs out straight (this was the most noticeable factor amongst the three aforementioned men with DR) and means that even just lying flat on your back, doing nothing(!) can actually contribute to a diastasis
Do your ribs do this when you lie down?
Tight shoulders and chest muscles which will lift the ribcage and create a lateral pull on the LA every time you reach overhead
Constantly increased intra-abdominal due to chronic digestive upsets and bloating
Repetitive increased intra-abdominal pressure via habitual movement and exercises (think repetitive sit ups, straining on the toilet, breath holding, or ALWAYS sucking in your stomach)
When you think you're doing this...
...But you're actually doing this!
What does this all mean?
All of these factors can cause stretching and thinning of the Linea Alba before babies. But when combined with the pregnancy-related hormonal softening of the connective tissue, plus the added pressure, growth and load of a baby, it makes postpartum diastasis recti much more likely. While the extent of diastasis recti is also affected by some genetic factors (such as your particular collagen makeup), I propose that addressing these factors before and even during pregnancy would be helpful to decrease severity of postpartum DR. —> If anyone is interested in setting up a clinical trial with me, let me know! :D
If you do have a DR postpartum, just working to strengthen the deep core abdominal muscles (eg. pelvic floor and TrA) may give you limited results without addressing these other non-pregnancy related factors. In fact, you might be actually working against yourself while simultaneously trying to bring these muscles ‘back together’.
Keep an eye out for Part 2 of this Understanding Diastasis Recti series - how YOU can start resolving DR and restoring your core function.
And if you can’t wait till then, I highly, HIGHLY recommend getting your hands on a copy of Katy Bowman’s book Diastasis Recti - available in both eBook and hardcopy format. (Note: I do get a small affiliate percentage for any books and products purchased through this link, but even if I didn’t I would still recommend it anyway). This is the first book written on DR which takes a whole body perspective, with progressive exercises and is very easy to understand.
*Prices in the NM bookstore are all in USD and do not include international postage.
For anyone in Australia who is wanting to buy one - I do have a limited number of hardcopies available for purchase ($24 AUD inc GST + domestic shipping if required) to save you international postage rates. Contact me at info@bodyandbirthphysio.com if you would like a copy.
