The word “diastasis recti” (DR) often strikes fear and panic among women who have heard of it, or sheer confusion among those who haven’t (even trying to pronounce its name is difficult enough). And it’s no surprise. There is a great deal of mis-information and myths surrounding DR (a separation of the rectus abdominis muscle) — from how it’s caused, to who it affects, how to detect it, and even how to heal it. We break everything down for you here in a clear and simple fashion — dispelling common myths, and setting the facts straight. After all, the actions we take as trainers can either help, or exacerbate, this issue — and we want to ensure you’re doing the former.
What diastasis recti is
In short, diastasis recti (DR) is a separation of the right and left sides of the rectus abdominis muscle (that is greater than 2.7 cm or about 2 finger widths) due to a thinning and weakening of the linea alba tissue that connects the two sides. The word “diastasis” means separation, and “recti” refers to the rectus abdominis muscle. It can manifest as a “torpedo-like” protrusion in the belly during any movement that engages the abdominal muscles, as you see in the image below.
Beyond the annoying “pooch-like” appearance, DR may indicate a weak and ineffective core. This can lead to a host of problems including low back pain, pelvic or hip pain, incontinence, constipation, or prolapse. It can also increases the risk of developing a hernia (when internal contents actually protrudes through a weak point in the abdominal cavity). Hernias require surgery to address, whereas DR can typically be healed without surgery.
What causes diastasis recti
Simplistically speaking, it all comes down to one thing: excess intra-abdominal pressure (IAP). To explain further, let’s take a look at the image below. As you can see in the image on the left, all the abdominal muscle layers (transverse abdominis, internal and external obliques, and rectus abdominis) – are connected at the front of the body by a tissue called the linea alba. The linea alba is fascia, and (as we describe it to clients) has a consistency similar to “silly puddy.” It’s strong, but flexible. If consistent and excessive outward pressure is placed on that tissue (like from a growing belly during pregnancy), then it eventually thins and stretches so much that its consistency becomes more like cellophane, and it loses its ability to hold anything together. When this happens, the outermost muscle layer – rectus abdominis – begins to drift apart, as in the image on the right below.
As should be pretty obvious, a growing belly during pregnancy adds a great deal of IAP. This is why Diastasis Recti is actually a normal and natural part of pregnancy. The abdominal separation is necessary to allow baby room to grow. In fact, some studies show that 100% of women will experience diastasis recti during their 3rd trimesters. If managed appropriately, the DR will heal within a few months after delivery. So your pregnant clients do not need to panic about completely avoiding this natural part of pregnancy. However, other factors (which we will discuss next) can further elevate IAP levels beyond the level already caused by the belly. This is when DR can become an issue — and remain one in the postpartum period.
What factors make a person more susceptible to getting DR?
Basically, anything that creates excessive IAP will lead to greater risk of DR. So, when it comes to pregnancy, the larger the belly, the greater her DR is likely to be. Some of this may be unavoidable (like if she is having multiples, or has a smaller torso with less room for baby to grow up and down). However, there are many other factors that further elevate IAP levels, and all of these, we can control:
- Alignment Shifts: The greater the anterior pelvic tilt, the greater the pressure on the linea alba tissue.
- All the following movements performed with a larger belly: Spinal flexion/extension in the sagittal or frontal plane, rotation with disassociation of hips and shoulders, full center and side planks, and any other advanced core exercise like V-sits, leg lifts, hollow body holds.
- Slouching or poor bending over technique: Slouching is crunching (spinal flexion), as is bending over with a rounded spine vs. hinging at the hips and maintaining neutral. Unfortunately, many people spend a good portion of their day slouching and bending over with poor form.
- Weak “Core Canister” muscles: When the Core Canister muscles (diaphragm, transverse abdominis, and pelvic floor) are strong and properly functioning, they act as a pump to help regulate IAP. If these muscles are weak, they cannot effectively manage the pressure. This is why you often see DR in babies, like below, because their core muscles are not fully developed. Don’t worry, this DR will resolve as they grow!
- Sucking in: This refers to drawing the navel in on the inhale (what we refer to as “backwards breathing”). This method of breathing actually increases IAP.
- Chronically engaging core: Even if an individual engages properly (drawing the navel in as a result of the exhale), keeping the navel consistently or chronically engaged also leads to an IAP buildup because this essentially “shuts off” the Core Canister pump.
- Breath holding during exertion: Breath-holding during exertion (or Valsalva as it’s referred to) dramatically increases IAP. This increase in IAP actually creates more power, which is why powerlifters, or individuals doing heavy lifting, use the Valsalva technique. It helps them lift heavier loads. The downside of this is that it can lead to DR, like you see in the image below.
- “Bearing down” on the toilet: This is Valsalva as well (breath-holding during exertion). We often do this when constipated because it increases IAP to provide more power to push. Again, the downside is that it can lead to DR. Unfortunately, hormonal changes during pregnancy actually increase the likelihood of being constipated.
How to check a client for diastasis recti
We do not typically check for DR when a client is pregnant because many women don’t feel comfortable with you pushing on their bellies. In addition, we know that pretty much every woman will get it during her third trimester, so we can expect she’ll have it a bit. We also recommend waiting until a woman is at least 6 weeks postpartum to check her because every woman will still have a separation in the immediate aftermath of labor. It will close a bit over the next 6-8 weeks. So wait at least that long.
Watch the video below to learn how to check a client for DR. Note that it’s important to always ask a client permission to touch her abdominal area. Many women are quite sensitive about this after delivery. If she is not comfortable with you checking her, you can instruct her how to perform a Diastasis Self-Check.
As discussed in the video, while DR is specifically defined by width only (a separation of more than 2.7cm), newer research is showing that depth of separation is actually a greater indicator of how compromised the linea alba tissue is. When we refer to depth, we mean how far you can sink your fingers down into the separation. In other words, if you feel a separation between the left and right sides of the rectus, does that separation seem pretty shallow and taut? If so, that’s a good thing, and will likely heal faster. However, if that separation feels soft and squishy, allowing you to sink your fingers down into the gap, this indicates a more compromised linea alba that will take longer to heal. So, technically a woman with only a 2 finger separation, but a deep gap has a more severe DR (that will likely take longer to heal) than a woman with a 3 finger separation and shallow gap.
How to help prevent or manage DR
- Coach her into neutral alignment: Help her counteract the anterior pelvic tilt to alleviate pressure on the linea alba and PF. Be sure to focus on her SEATED and BENDING OVER alignment (ensuring she’s in neutral), as slouching and rounding at the spine increase IAP.
- Develop strong Core Canister functioning: Master 360° Breathing, and ensure she incorporates this into all her movements.
- Avoid “aggravating” core work as belly grows: Spinal flexion/extension, rotation with disassociation of hips and shoulders (twisting), and advanced core exercises (leg lifts, v-sits, etc).
- Regress ALL plank-like movements as belly grows: This includes center and side planks and any plank-like movement (push-ups, renegade rows, burpees, etc).
- Avoid sucking in and chronically engaging: Your clients may be tempted to do this (especially in the earlier days of pregnancy when they have not announced it yet and want to hide their bellies), but educate them on how these behaviors can have the opposite effect on their bellies.
- Avoid Breath-holding during exertion: This includes not just the use of the Valsalva technique, but also things like “bearing down” on the toilet during a difficult bowel movement. Read these tips on things she can do to help reduce constipation during pregnancy.
- Any move that triggers “coning”: Always be on the lookout for that “torpedo-like” protrusion we showed above. If you see this, it’s a sign that movement is NOT appropriate. Don’t panic, just stop the movement and find an alternative.
- Follow the PROnatal “Core Recovery” Protocol: We teach a 3-level Core Recovery Protocol in our Pre/Postnatal Performance Training Specialist Education. We take every postpartum woman through this protocol to rebuild the core post-birth, but it can also be used during pregnancy if DR is severe or painful, and for any client with weak core muscles.
- Refer to physical therapist if necessary: If you have not been through any sort of training on DR, it is best to refer your client to a pelvic floor, or women’s health, physical therapist. If you have had some training (such as the PROnatal training), you can likely work with women up to 3 finger separations and moderate depth. In severe cases, we always recommend referring to a physical therapist.
Want to Learn More?
Consider taking our Pre/Postnatal Performance Training Education. It may even benefit you personally, like the feedback from one of our Online Course Participants below:
I was suffering from moderate Diastasis Recti prior to taking this course. Using what I learned in the course, I was able to heal it by the time I completed it. My OB/GYN was amazed at how great the PROnatal Core Recovery Protocol worked!
Alexandra Advanve, Certified Personal Trainer