Diastasis Recti Abdominis (Separated Abs)
Okay, here she is. The topic I get asked about most often, and the second most common (physical) postpartum issue, after stress incontinence.
In plain english, Diastasis Recti Abdominis (DRA) means that your ab muscles have separated,
And in some cases they've divorced.
DRA is all too common to mummas during and after pregnancy, but you should know that it can happen to ANY BODY. The stats vary, as they always do depending on who you ask, but approximately HALF OF ALL WOMEN will have some degree of DRA during their pregnancy years, but really ALL women develop it during their third trimester when it just has to stretch to accommodate your growing belly. In my opinion, we shouldn’t consider third trimester separation as the injury we term DRA.
The severity of diastasis recti can vary from mild enough that it will heal up on its own (lucky you - odds are you never knew you had it), to very severe cases that require surgery to repair the damage (rare). Most cases fall somewhere in between, requiring corrective exercise, education and therapy heal it up.
This is your guide to DRA.
What is diastasis recti abdominis?
Let's be smart about this and take a close look at the anatomy of the abdominal area.
Observe the six pack. This is the rectus abdominis muscle.
Note the vertical line separating the left and right sides of 'the pack'. This is called the LINEA ALBA - a band of connective tissue that joins the two sides of your core muscles. It extends from the tip of the breast bone, alllllll the way down to the pubic bone, which we unfortunately can not see on Mr. Reynolds.
Simply put, Diastasis Rectus Abdominis is a injury to the linea alba. It has lost it's tensile abilities, resulting in a weakened abdominal wall. The laxity at the linea alba will present as a gap between the two vertical ab muscles.
For a FUNCTIONAL abdominal wall, and ultimately the entire core canister, you need tensile strength along the linea alba. Tensile strength means that the tissues can be loaded without failure locally (ab wall) and distally (core, pelvic floor, spine, hips, etc.).
What causes Diastasis recti abdominis?
Oh mumma, this is a biggy. I could talk for hours on this, but I'll try to keep this brief.
First, you should know that ANY BODY can get DRA - men, babies, kids, the strong, the weak, the fit, the unfit. And this is precisely why DRA is a complicated beast - it's not just about pregnancy, but it is pretty much a guarantee that pregnancy will cause it (again, I have a hard time calling the strained or stretched linea alba DRA during pregnancy).
The reason why the prevalence of pregnancy related DRA is so high is pretty obvious - the growing human(s) needs room which means things get stretched in an insane way. Tissues need to stretch.
The stretch and strain on the linea alba is inevitable during pregnancy, but there are strategies to prevent injury from happening. Is it a guarantee? No, but the research is positive. These strategies should start before pregnancy, continue through pregnancy and immediately after birth.
So, yes, diastasis recti abdominis is super common among us pregnant and postpartum folks. In fact, most studies indicate that 75-100% of women in their third trimester have DRA. Of these, almost 40% will have DRA at 5-7 weeks postpartum. And almost 70% of older women who have pelvic floor support related issues (incontinence, prolapse) have DRA.
Think of pregnancy as the (crappy) springboard that launches so many of us into the DRA diagnosis because pregnancy comes with so many HUGE body changes. Remember my little "these are the most body stressing times of your life" chant, so let's prepare, prevent and repair. Unfortunately, so many of us are not prepared for these huge body stresses that break us as soon as that little plus sign shows up. DRA happens when those body changes catch up with you; when the new loads and forces are not tolerated, something gives. In the case of DRA, it's the linea alba.
The linea alba is especially vulnerable to injury because of its anatomy and the fact that it is connected to just about every structure in your core. And we know that your core is connected to just about every other part of your body. So you do the math. Alotta play'as, mummas. It's a structure that is under a lot of pressure, figuratively and literally!
non-optimal loading forces cause diastasis recti.
What the heck does this mean?
Forces push and pull on us all day long. Your body reacts to (absorbs, transmits, dampens, etc.) these forces well or not so well. If it responds to the forces and loads well, no injury occurs. If it responds poorly, injury happens. In order for tissue to 'tolerate' the push and pull and loading every single minute of the day, you need to make sure you have ALL of the following things going for you:
STRENGTH: If this is lacking, you will lack the ability to move efficiently and with good alignment, which may result in undue strain on your linea alba. The core muscles should take some of the load off the linea alba, which is hard to do if they are weak. Other muscles that are important: glutes and pelvic floor.
ALIGNMENT: If this is lacking, forces and loads imposed on the core/linea alba (and any other body part for that mater) may be more stressing to the tissues, joints, etc., increasing the risk of injury. For example, if you walk around all day with you lower ribs flared up and out (like so many pregnant women do), your linea alba will be under constant strain. If you then go to lift your giant toddler out of his car seat with this stressed linea alba, you risk deforming it further. And on and on it goes.
FLEXIBILITY: Tissue needs to be flex-able (able to flex, got it?) in order to resist being over stretched; if tissue has too much tension (is tight), it will have a hard time adapting stretch forces, and may deform. Think of a muscle like your hamstrings: if you don't have full flexibility to do the splits, you will surely injury your hamstrings if you try. Same goes for your belly muscles: if they are not able to accommodate your growing belly, your linea alba will be strained from the excess tension. This is sometimes where we see mummas (or the massive 6-pack gym dude) with DRA because of their super strong ab muscles that carry too much tension.
PRESSURE: This has to do with flexibility, strength and alignment (of your trunk), but I like to talk about it separately because it's a biggy. Your internal pressures (in your chest, belly and pelvis) all affect your core muscles, especially when pressures are chronically increased. Increased internal pressures means more tension on your core muscles, and that vulnerable linea alba. So whether you are a belly sucker-inner, or a chest breather, or a bloated-by-5pm'er, or a chronic cougher, you are putting extra strain on your linea alba, among other things. Add pregnancy to the mix, and you have the perfect recipe for disaster. I mean diastasis.
If any one of these four players is out of whack, you risk injuring that vulnerable linea alba. These factors are dependent on each other (ie you need strength for good alignment, you need flexibility for good alignment and functional strength, you need balanced pressures for optimal alignment and tissue flexibility etc. etc.).
Aaaaannnnnd, if that's not enough, there's those little hormones relaxin and progesterone.
Most mummas have a love-hate relationship with these powerful hormones. They both cause your pelvic ligaments (in particular) to well, relax. This is a good thing because it allows you to birth a baby. Excellent. But it also means that you are vulnerable to instability, which may affect things like how you carry yourself (alignment). Which usually translates into strain on your core (and spine, and pelvis, and hips, and, and, and).
And that vulnerable linea alba.
Poor linea alba. Always taking the brunt of non-optimal forces.
And so, it's okay to blame your DRA on pregnancy, but know that it's a whole body issue. Pregnancy was the straw that broke the camel's back, or in this case your linea alba. Knowing what the major players are in causing diastasis recti abdominis is key to preventing it from happening or fixing it and getting back a functional abdominal wall.
I have "Mummy Tummy", does this mean I have DRA?
Ack! I hate this term. Just as a flat tummy CAN have a diastasis, a tummy with a pooch CAN NOT have a diastasis. Having excess abdominal fat or tissue is unrelated to a diastasis recti diagnosis. The research does not indicate that one causes or is indicative of the other. The goal of correcting a DRA is to achieve a functional core, not a flat one. That said if you start working your core, to correct a DRA or not, you will likely be pretty happy with the results. #winwin
How do you know if you have DRA?
You can perform a simple self-check to see if you have DRA. If after doing the self-check you think you have a diastasis, even mildly, you should see your preferred physical therapist for a proper assessment and treatment plan.
how to do a Diastasis Recti Self-Check
Lie on your back with your feet flat on the floor, knees are bent. Using your fingers, feel the spot right above your belly button. Your linea alba passes right here. Keeping your fingers firmly in place, lift your head and shoulders just off the floor, this will engage your abdominal muscles. You should feel the ab "walls" squeeze on either side of your fingers. Adjust the number of fingers so that they span the width of this gap.
You want to feel for two things:
1) The WIDTH of the gap between the two ab muscles. How many finger fit? Generally more than 2 finger widths is considered DRA.
2) The TENSION of the linea alba: is it taut or slack?
Relax your head and shoulders back down, reposition your fingers a inch or so further along, towards your sternum and repeat the process. Repeat this test along the entire length of the linea alba, above the belly button and below, towards the pubic bone.
Typically, DRA is worst around the belly button or just above it, but DRA can occur anywhere along the length of the linea alba.
What is normal?
Before you got pregnant, there may have been an average linea alba width that you could compare yourself to. This is some average that some scientists came up with after doing a bunch of math. The width of the linea alba in nulliparous women (those who haven't delivered children) VARIES SIGNIFICANTLY though. Just like any body part, comparing sizes (or widths in this case) is kinda redundant. And imagine how much more the numbers would vary if these scientists looked at averages of PAROUS women (I couldn't find anyone who has, probably for good reason - waste of time).
The important thing here is NORMAL FUNCTION. And remember, the TENSION of your linea alba and how your abdominal wall functions is what's important. That said, I do suggest that you get your abdominal wall checked out if your width is 2 or more fingers wide.
Tension is a little trickier to judge or feel for. I like to use a little cheat sheet when I'm informing my patients of what they should feel for: use the webbing between your thumb and index finger on the back of your hand as a guide. Kinda like using different parts of your palm to determine steak doneness. It's almost the same thing.
You want FIRM. The linea alba is meant to stiffen up (like a guy-wire) when your core engages, especially with a mini crunch as in your DRA self-check (see above). Also know that it's the LINEA ALBA that you (or your therapist) are assessing, not the skin or fat tissue on top. Dig in and feel for that tension. If you don't feel any tension and it's SOFT (spongy?) or LAX (empty? a pulse? sinking in up to your knuckles?) you should give your favourite physical therapist a call to get it better assessed and get treatment started.
What are the consequences of Diastasis recti?
This depends on the severity of the separation and state of the tissue, and your overall core health. A small separation might not affect you at all. Although, considering the importance of this area odds are you will experience some issues:
pelvic organ prolapse (POP)
difficulty with labour and delivery
lower back pain or hip pain
Over half of all women with DRA present with pelvic floor support issues (incontinence or organ prolapse).
You can read more about pelvic floor health here.
Will my gap close?
This depends on a few factors: 1) the severity (width and tension) 2) your pre-existing core strength 3) your BMI (body mass index), 4) your age, and 5) your commitment to doing corrective exercise and changing HOW YOU MOVE. If the case is mild, it has a great chance of returning to pre-injury condition (in terms of width and tissue quality). If the case is more moderate, there is a chance that the gap can close to some degree, but it can definitely improve in tension. In severe cases, surgical repair may be necessary.
HOW DO I prevent OR REPAIR DIASTASIS RECTI ABDOMINIS?
You can prevent diastasis recti. I have with all three pregnancies, and I’ve seen countless women who have as well. And at the very least, you can lessen the severity of it. The research backs this. I know there are mixed messages about whether you can or cannot prevent DRA, but from the literature reading I have done, my own clinical experience and my own personal experience, I know that you can prevent diastasis recti. The linea alba may stretch beyond it’s normal width during the third trimester, but preventing injury to it is doable.
Diastasis recti abdominis can also be fixed with corrective exercise and education. And if you are thinking that it's too late ("the twins were born 5 years ago!"), you should know that there is still a lot you can do. Regardless of whether you are aiming for prevention or treatment of it there are a few things you must know.
FIRST, know what you should AVOID:
Sit-ups & Crunches or any exercise that has you flexing your trunk against gravity - there are many. I will rant about these another day, but for now just don't do them. Ever. Yes, ever (I know, best news!).
"the Bulge". Avoid any exercise or movement that makes your belly bulge or balloon outwards beyond your normal. This may include any exercise (i.e. a plank) or daily activity (i.e. lifting groceries). If it bulges, it means that you are either not engaging your core properly or that your core muscles are too weak for the force that is being imposed on them (see causes of DRA above). It may or may not mean you have DRA, but it should be avoided. If you can prevent it from bulging by contracting your core properly, please do. If you can't, then avoid the exercise or the task all together.
Stretching the Stretched. This should be a no brainer, but it's often forgotten. If you sprained an ankle (over stretched ligament), you wouldn't stretch it out (more!) to help it heal. Same with your linea alba. Avoid stretching your ab muscles. This might include lying on a ball and arching backwards, or cobra, updog, bow, camel and triangle poses in yoga, cat/cow (the cow part in particular) - pretty much if it has an animal name, avoid it.
Heavy lifting. Obviously all lifting can't be avoided (hello, baby) and "heavy" is relative, but please ensure that it is always done properly for the sake of your back (using your legs and hips), but be especially careful (or avoid it entirely) if the task is to lift something really heavy, if you are in your third trimester, or are especially weak in the core department. If you can't control "the Bulge" (see #2) or maintain proper posture during a lift, skip it if you can.
"the Heave". We all do this. This is the getting-out-of-bed heave. From lying on your back to sitting upright in a split second. This will not only strain your weakened ab muscles, but it will also kill your back if you do it all the time. Roll onto your side and use your arms to push yourself upright. Also, any exercise (hello, pilates!) that involves a sit-up/curl-up movement should be avoided (see #1).
Coughing/Sneezing. Okay, so this is slightly impossible to avoid, but especially in your last trimester or if you have been diagnosed with DRA, try to think about engaging your core (bracing, but still breathing) before a sneeze or a forceful cough (engage your pelvic floor too while you're at it!). If you know you DRA, you can also consider manually splinting your abs to protect the area further.
What do you need to prevent and/or repair Diastasis recti abdominis?
You know the answer to this already, mummas. The solution to preventing and repairing DRA postpartum is:
a healthy CORE.
What exactly does this mean? How will you ever repair your core when you need a healthy core to repair the broken core?!!!
A healthy core doesn't mean a strong as a rock core. Having a healthy core means that you can:
contract it properly
relax it properly
load it properly
and regulate pressures well.
All of this means that you need to know YOUR body.
It is very difficult (and some might argue impossible) to prevent, and definitely to repair, diastasis recti, unless you have been seen by a physical therapist. Even as a therapist, it is important that I see someone postpartum. I can’t watch my abs through different loading exercises to see where they do well and where they fail.
So while a healthy core is what you need to prevent and repair diastasis recti, the first step is seeing a physical therapist to know where your core is at and give you the strategies you need to heal and achieve the level of function your need and want.
two simple rules for preventing and repairing DRA:
1. Learn to engage your core properly. If you missed it, check out this post on how to engage your core properly. The same rules apply for DRA: no sucking in, no pushing out, no bulging, no spine flexing. Regulating pressures falls into this category. this is where seeing a physical therapist is a must.
2. Be mindful of your alignment. How do you walk? How you do you sit? How do you squat? Is your body moving the way it should? Has pregnancy totally thrown you off kilter?
Whether you are pregnant or not, do your best to keep your core engaged every minute that you are fighting gravity. Your belly is soft and moving with your breath, but it is engaged - 10%? 30%? 90%, it will vary depending on the loading forces. But it is always on and aware. It adapts to the forces imposed on it. You are training your core in the best way possible when you focus on it throughout your day.
Your conscious CORE awareness
will eventually translate into unconscious work.
This constant awareness and engagement of your core is especially important during pregnancy and in the early postpartum months: sitting, standing, rising, lowering, walking, running, dancing, driving, biking, lifting, carrying, coughing, sneezing, scrubbing, vacuuming…
Core. Core. Core.
What about bracing/splinting/binding devices?
There is little scientific support for the use of abdominal splints postpartum to aid the healing of DRA or other abdominal wall injury. These devices are believed to bring the abs together, allowing them to heal faster. The problem with any brace or support system is the likelihood that muscles will weaken over time due to the external support. Proper education on the use of these braces is crucial so that this doesn't happen. In my opinion, a brace should only be considered as an adjunct to the overall treatment plan for correcting diastasis, and typically only in severe cases. Its use should be limited, monitored and dependent on the severity of the DRA and the overall core health. Talk to your physical therapist before using any abdominal splint, brace or binding method.
Hope this helps. There is so much to say about DRA since it is a whole-body issue. My biggest advice is to speak to a trusted physical therapist. Get assessed, get educated (on YOUR body) and get a treatment plan for you. If you live in Ottawa I'd be happy to help!