Diastasis Recti “The Mommy Tummy”

Diastasis Recti Abdominis (“DRA”) has been a big topic in social media lately. But, what really is DRA? Some people experience DRA as a big gap in the middle of the belly, or as a “pooch” in the lower abdomen that is hard to get rid of. As physical therapists, we know DRA as abnormal lengthening or distortion of the linea alba. The linea alba is the midline of the abdomen where the abdominal muscles attach to. Because there are so many programs out there attempting to “FIX” the mommy tummy, it’s important to understand what DRA is, how it arises, and what we are looking for during treatment. Diastasis recti abdominis is most commonly measured through inter-recti distance (how wide the linea alba stretches) during a neck curl-up. It is considered a DRA if you have 2- finger width or more of widening of linea alba. Inter-recti distance is measured 2 inches below the belly button, at the belly button and 2 inches above the belly button. However, you’ll see later in the article that this is not the only sign of abdominal dysfunction.

The Many Myths of DRA:

1.   DRA is only affected by pregnant/postpartum females
2.   The linea alba is 100% intact prior to pregnancy
3.   It’s a separation of the midline.
4.   Everyone should do transverse abdominis/pelvic floor muscle strengthening
5.   Treatment will help CLOSE or FIX the gap. 

Myth #1: It is possible for both males and females to experience DRA. It can be something that people are born with, poor pressure management during workouts and weight lifting and/or rapid changes in weight. Babies are sometimes born with a bulge in the abdomen, but usually recovers on its own as the tissue matures. However, DRA is most commonly seen in pregnant and postpartum women. Sperstad, et al in 2016 followed 300 pregnant women and found the prevalence of DRA was present in 33.1% of people at gestation week 21, 60% at 6 weeks postpartum, 45.4% at 6 months postpartum and 32.6% continued to have a DRA at 12 months postpartum. 

Myth #2: If you are newly pregnant, or thinking about getting pregnant in the near future, it’s not a bad idea to have someone or your physical therapist measure your baseline! Some people have some inter-recti distance prior to being pregnant (like me)! It’s always good to know where your baseline is and to track it as the pregnancy progresses. It is also important to know it is normal to have a DRA by your third trimester. Mota, et al in 2014 reported 100% of 84 women had a DRA at gestation week 35. However, it is a great idea to be proactive and understand how to use your abdominal muscles correctly as there is a higher demand on the ever-changing body during pregnancy. There are some studies that do show core strengthening during pregnancy or before can help reduce the severity of the DRA. (Werner)

Myth #3: As we are getting more and more information about DRA, we now know that there is no SEPARATION, but rather the linea alba tissue has been lengthened or stretched. In other words, the tissue has become distorted and/or dysfunctional (Lee). When the tissue is distorted in any way, the ability of the linea alba to transfer forces towards the opposite abdominal wall is then impaired and can lead to decreased protection of the abdominal contents and instability in the thoracic or lumbar spine. Often, people are looking for separation, but many times in my clinic I see the opposite! Many people bulge up into the middle. This is also a sign of abnormal tensioning of the linea alba and can be as damaging as the lengthening of the linea alba because it is not able to transfer load appropriately to maintain stability in the spine. This is usually a sign of imbalance between the abdominal muscles. While all of the abdominal muscles are as important, it is the balance and contribution of all of the abdominal muscles AND the pelvic floor AND the diaphragm AND the back muscles that create a stable unit together.  If you notice either a gap/divot or a bulge in the middle during your neck curl-up or lifting, visit your pelvic floor physical therapist. 

Myth #4: You may have read on the internet or on social media to focus on transverse abdominis muscle and pelvic floor muscle strengthening. The transverse abdominis (TA) muscle is the deepest abdominal muscle and has connections to the thoracolumbar fascia that surrounds your back. In addition, the TA has the majority of its fibers lying in a transverse fashion below the belly button with direct connections to the linea alba. This is where we can generate the most tension in the linea alba. This is the reason why we focus on TA strengthening to help with DRA- and it works! But the other players are also important-the other abdominal muscles, the multifidus, diaphragm and pelvic floor muscles and how they interact with each other. For example, the transverse abdominis and pelvic floor muscles are synergists; they often co-contract simultaneously. Because of this relationship, we have to be careful with this rehabilitation approach. Are you having any other symptoms? Are you struggling with pelvic pain/pressure, incontinence, urinary urgency/frequency, pain with sex? More often than not, pelvic floor muscle contractions or “kegels” are NOT the answer. Many of my patients’ pelvic floor muscles are not lengthened or weakened, but in fact hypertonic. When the muscles are hypertonic, or tight, the pelvic floor muscles can’t do their job of supporting the pelvic organs, maintain continence, and enjoy sexuality. Hypertonic pelvic floor muscles can manifest its symptoms through the bladder and/or bowel. In this circumstance, the focus of the treatment should first be to release or relax the muscles. That is why it is crucial to have your assessment/examination completed by a skilled pelvic floor physical therapist prior to exercise programs. 

Myth #5: As the DRA topic is more main-stream now (YAY!), there are a lot of programs out there targeting treatments to “FIX” or “CLOSE” the gap or pooch. We now have research through real-time ultrasound and other great technology that people who recover from DRA actually did not have improved/decreased inter-rectus distance. However, after rehabilitation, the linea alba was able to transfer the load appropriately during activities.  Even though the gap didn’t “close,” people still reported improved quality of life and improved appearance (Lee). Instead of thinking about closing the gap, think about tensioning the linea alba! 

Bottom line:

There are things to consider when starting an exercise program. If you have DRA, you absolutely can exercise. But please note...

-your breathing/pressure management while exercising 

-strength, coordination and timing of pelvic floor, superficial and deep abdominal muscles, and low back muscles

-pain level (there should be NO pain!) 

-maintaining continence (NO leaking!)

 Even though DRA may be normal during pregnancy, it can still be addressed. We are looking for the functional strength of the core so that you can carry out basic everyday activities like holding your newborn or toddlers, lifting groceries, getting up from the floor, transferring your young kids to the car, etc. When in doubt, come visit a PT! 

Written by: Carly Soltman, PT, DPT, Pelvic Floor Specialist 

References:

Lee, Diane. “DRA Should we Open or Close The Gap.” DianeLeePhysio. https://dianeleephysio.com/education/diastasis-rectus-abdominis-postpartum-health/

Mota, PGF, Pascoal, Carita A, et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Ther. 2014:20 (2015) 200-205.

Sperstad, JB; Tennifjord MK, Hilde G, et al. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016; 50: 1092-1096.

Werner AW; Dayan M.Diastasis Recti Abdominis-diagnosis, Risk Factors, Effect on Musculoskeletal Function, Framework for Treatment and Implications for the Pelvic Floor. Current Women’s Health Reviews 2019; 15 (2):86-101.