Diastasis Recti

July 2, 2019

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Today’s post is part two of a postpartum series inspired by a reader question. You can read part one here.

Diastasis recti (DR) is usually described shorthand as a separation of the ab muscles. More accurately, it’s a deformation of the linea alba, the line of connective tissue that runs down the front of your torso from your ribcage to your pelvis. The linea alba is basically where all the abdominal muscles meet in the middle; I think of it like the spine of a book. When the linea alba becomes deformed for reasons I’ll discuss in a moment, the rectus abdominis muscles, aka your “six-pack” muscles, pull apart. This is the (often visible) sign of DR.

More than a cosmetic issue, this compromises the integrity of your core and can be associated with a whole host of other problems if not corrected. Although it’s difficult to establish clear causal relationships, DR is often related to pelvic floor issues and incontinence, back pain, hernias and prolapses, and difficulty exercising. While some DR resolve on their own, often they require intervention—targeted exercises to bring the muscles back together or, in some extreme cases, surgery.

What Causes Diastasis Recti?

To understand DR, you have to understand that the abdominal cavity is always under pressure. Wedged as it is between the thoracic (chest) cavity and the pelvic cavity, the pressure in your abdomen is always shifting based on your breathing, movement, digestion, and so on. If the pressure isn’t too great, it’s no problem. However, when the pressure increases—say perhaps because you have a growing baby taking up more and more space in there—one of the ways that pressure can manifest is by pushing outward on the front of the belly. The linea alba stretches and weakens, and the rectus abdominis ends up abnormally separated.

I say “abnormally” because some separation can be classified as normal, especially during pregnancy, and can simply reflect individual structural differences. Estimates of the prevalence of DR among pregnant women range from 66%-100% of women experiencing some degree of DR by the end of pregnancy. Abdominal separation that does not resolve on its own soon after pregnancy, or DR not associated with pregnancy, needs to be addressed as soon as possible.

That’s right—men, children, and women who have never been pregnant can all have DR. Any conditions that increase intra-abdominal pressure and stretch and weaken the linea alba can lead to DR. These include things like overdoing traditional ab exercises like sit-ups, chronic coughing, and chronic constipation leading to straining. Injury to the linea alba, including from abdominal surgery, is another risk factor.

Renowned biomechanist Katy Bowman believes that alignment (how we hold our bodies throughout the day), movement, and even breathing all play a key role in preventing or developing DR. This isn’t to say that breathing incorrectly will make your abs split apart. Rather, the types of loads we place ourselves under can make us more or less susceptible to developing DR. On the flip side, by fostering proper alignment and movement patterns, you might be able to avoid DR even during and after pregnancy. More on this later.

How Do I Know If I Have Diastasis Recti?

Unfortunately, DR is often overlooked even in the antenatal and postpartum periods. However, it’s easy to test for yourself whether you have DR. The most obvious sign is if your stomach bulges when you do a traditional crunch (don’t do crunches if you think you have DR, or ever really—they aren’t a particularly safe or effective ab exercise), cough, or otherwise load your abs. This might look like a small football in your tummy, a loaf of bread, or just a mound. It is most likely to appear right around your navel, but it can also happen above or below your navel, or all of the above.

Even if it’s not visible, if you have pelvic floor weakness (no ladies, we shouldn’t be peeing when we run or jump rope), chronic back pain, hernias, or even digestive issues like constipation or bloating, you should check yourself for DR. Likewise if you feel like your abs are weak or aren’t holding you in, for lack of a better term, perform a self-test.

To do this, lower yourself carefully onto your back and lie flat with your feet on the floor and your knees bent. Lift up your shirt and slide your waistband down so you can feel your abs from your pubic bone to your sternum. Take two or three fingers and with your palm facing you, press down firmly at the top of your navel while you slowly lift your head off the floor like you’re beginning a crunch. You should feel your rectus abdominis muscles tense on either side of your fingers. Relax your head back to the floor. Repeat this test below your navel and above your navel up to your sternum. (Check out the video here if you need more guidance.)

You are feeling for two things:

What is the gap between the ridges of your muscles? Anything greater than about two finger-widths is considered positive for DR. (The generally accepted medical standard is a gap of 2.7 centimeters.)
How “squishy” is the linea alba? In other words, how far down do your fingers sink when you press? Ideally your linea alba would feel firm and resist being pressed down.

Don’t freak out if your fingers sink down in there! Now you know and can do something about it.

I Have a Diastasis… Now What?

If you believe that you have DR, it’s a good idea to get it checked by a doctor so you can get a referral to a physical therapist if needed. Look for a PT who specializes in DR and, if applicable, postpartum fitness. While surgery is sometimes recommended for serious cases of DR, it’s not to be taken lightly and might be avoidable with the help of a knowledgeable PT. Of course this is a decision that you must make with your doctor. Mild-to-moderate cases are often correctable with simple at-home techniques, but especially if you’re pregnant or have recently delivered your baby, I am still going to advise checking in with your doctor first.

Even if your doctor determines that you don’t meet the medical criteria for diagnosis, the exercises suggested to resolve DR will be helpful for anyone wishing to improve alignment and increase core strength and stability. That’s to say, even if you don’t have significant DR, you’ll likely still benefit from what I call the ABCDs of fixing DR. They are generally regarded as safe during pregnancy to help mitigate the damage of DR, but always talk to your doctor or midwife to be sure.

Alignment

Katy Bowman reminds us that we can’t look at any one body part in isolation. While we might think of DR as a problem in the abdominals, in fact the pelvis, abdominal muscles, and ribs are all connected. Moving any other body part that also moves the pelvis or the ribs will therefore affect the abdominal muscles and connective tissue.

Katy’s book, Diastasis Recti: The Whole-Body Solution to Abdominal Weakness and Separation, is a great resource. She focuses on proper alignment as both a preventative and restorative practice, and then she walks readers through a series of whole-body exercises, starting small and progressing to larger movements, that can improve DR. Her alignment checklist is as follows:

Straighten your feet
Back your hips up
Align your knee pits
Adjust your pelvis
Drop your ribs
Relax your diaphragm

For help understanding what this looks like in practice, I recommend starting with this video. It’s designed for runners, but it demonstrates the same principles that are important here. Katy also provides tons of information and resources on her website, Nutritious Movement. (Start with her Under Pressure post.)

You can’t have proper alignment if you’re walking around in heels all day, unfortunately, so it’s time to embrace going barefoot and wearing minimalist shoes as often as possible. If you’re used to wearing heels or even just traditional shoes (which often have a heel lift that we don’t even notice), make sure you take care to transition to a minimalist/barefoot lifestyle safely.

Breathing

The goal here is diaphragmatic breathing that engages the transverse abdominis (TA) muscles. Quick anatomy lesson: What we call “the abs” are not just the rectus abdominis muscles that make the six-pack. There are actually layers of muscles and connective tissue criss-crossing around in there. The TA are the innermost layer. They wrap all the way around the torso from the spine to the linea alba, and they are often described as looking like a corset.

In order to close a DR, we need to be able to recruit the TA, which means connecting to it and learning to activate it in the first place. This is where diaphragmatic breathing comes in. I find it easiest to feel my TA and understand what diaphragmatic breathing is supposed to feel like when lying on my back, but you can also do this kneeling. Place a hand on your belly and try to breathe into your hand, meaning you should feel a slight expansion of the belly as you breath. You aren’t forcing your belly out, but you want the motion as you inhale to be under your hand, not in your chest.

Next, place your fingers just above your hip bones on either side. Inhale through your belly, then exhale with some force, making a hissing noise. As you exhale, imagine tightening your core so your fingers move toward each other ever so slightly. This is not sucking in your belly, this is engaging that TA that wraps around from your back. Your belly should neither suck in nor pooch out, it should feel like it’s flattening (even if you can’t see it). Another cue my trainer sometimes uses is imagining zipping up the “corset” from the pelvis to the sternum.

Feeling the flexion underneath your fingers can be helpful for knowing you’re doing it right. If you’re having trouble understanding the technique, check out this video for a demonstration. Once you feel really connected to the TA, you can proceed to other strengthening exercises.

Core Exercises—but Only the Right Ones

I’m going to reiterate here that it’s important to consult with your doctor if you are concerned that you have limitations that might make any kind of exercise unsafe or inadvisable for you. In the case of DR, it’s a good idea to find a physical therapist and/or someone trained in DR or postpartum fitness who can help check that you’re doing the alignment and TA activation pieces correctly, and who can advise you on proper core exercises.

That said, there is widespread agreement about what not to do if you have DR, and that is any core exercise that increases intra-abdominal pressure. These include traditional crunches and sit-ups and, yes, planks. I know planks are one of the Primal Essential Movements, but they aren’t for you right now. Likewise experts advise avoiding twisting motions such as Russian twists and even certain yoga poses; high-impact exercises such running; and full-body exercises that require core activation like burpees, push-ups, and pullups (two more Essential Movements bite the dust) and heavy lifting.

Yes, that’s a lot, and it’s a bummer. That means you shouldn’t sign up for a 5k or get back to CrossFit until you take the time to address the DR. Bear in mind, though, that if you can’t properly engage your core during exercise, you’re at significant risk for injury and additional problems down the road. Although you likely have to back-burner some of your favorite activities in the short term, long term it is worth it to fix the DR first.

In order to do so, you need to work on gentle, appropriate exercises to strengthen the entire core. I’m not a PT or personal trainer, so I’m not going to give you specific exercises here. As I mentioned, Katy Bowman’s excellent Diastasis Recti book includes a whole series of progression exercises, and there are many resources and programs available online. You can also check out the movements here, here, and here for examples of the types of exercises that are generally regarded as safe and beneficial for DR. Did I mention you should check with your doctor first and consult a PT if you can? Good. I will also put some additional resources at the bottom of the post.

Diet

Because DR can be thought of as an injury to the connective tissue, you can support recovery by eating a nutrient-rich, anti-inflammatory diet that includes a variety of vegetables, sufficient protein, and essential fatty acids to promote healing. Since this just so happens to describe the Primal way of eating, hopefully you already have this box checked.

Also include plenty of collagen-rich bone broth. Use it in cooking or simply sit on a mug of broth during the day. You can jazz it up by blending in different herbs and spices. My favorite is using my immersion blender to blend 2 teaspoons butter or ghee, ¼ teaspoon turmeric (an anti-inflammatory powerhouse), and a pinch of black pepper into a mug of ghee to make a frothy golden “latte.”

To Splint or Not To Splint?

Experts disagree about whether it’s advisable to wear a splint or brace to support the abdominals while you work on closing your DR. Since there’s no consensus, this is another area where you should consult your doctor or PT about your specific needs.

But When Can I Start the Real Exercise?

If you’ve recently had a baby, you probably miss the physical activities you couldn’t do later in your pregnancy. It’s hard to be patient and do breathing exercises when you really want to be going for a run and hoisting a barbell over your head.

I implore you to be patient. It will pay off in the long run! And please, please don’t push your body too far too soon because you’re feeling pressure to get back to exercise ASAP so you can “get your pre-baby body back.” With proper care, a DR might start to resolve in a matter of weeks, but realistically it might be several months or longer before it is fully fixed.

Only after you have done the foundational work of the ABCDs should you move on to other exercise. Make sure you’re selecting safer movements that don’t put excess stress on the DR. You should ease slowly into more strenuous or vigorous exercise, paying attention to how your body responds. If you can, work with a qualified trainer or coach who can help you determine a safe progression back into your exercise modality of choice.

What If My Post-baby Belly Isn’t DR?

Even if you don’t pass the two finger test, you can benefit from working on alignment as Katy Bowman describes, as well as working on activating the TA, the foundation of a strong and healthy core and pelvic floor. Everyone should be doing these things, really.

If you’ve done all this and still feel like you look bloated or pregnant despite being well into the postpartum period, you might be experiencing bloating due to food sensitivities or gut issues such as imbalances in the microbiome. Talk to your doctor or find a functional medicine practitioner to help you dig into that more. If your issue is an accumulation of fat in the midsection, that can be related to stress and excess cortisol. You can work with your doctor to diagnose this, and/or start working on your own to manage stress.

At the end of the day, you might also have to accept that your body isn’t going to look exactly the same as it did before, and that’s ok. If you’re struggling with that, please check out my previous post on postpartum body image for support.

RESOURCES:

Find a professional to help diagnose and treat your DR:

http://aptaapps.apta.org/findapt (Put in your search area, then select Women’s Health on the following page)
https://fit2b.us/diastasis-directory/

The following offer paid programs designed to fix DR. They are endorsed by a variety of individuals and professional organizations. We at Mark’s Daily Apple do not have personal experience with these programs.