Diastasis Recti is a core injury that is common in pregnant and postpartum women, but certainly not exclusive to this population. It is essentially a “pressure problem” that can occur in women and men of all ages, even babies (though it usually resolves itself as babies grow). If not treated appropriately, diastasis recti can lead to significant low back pain, pelvic or hip pain, incontinence, constipation, bladder or rectal prolapse, and more — not to mention aesthetic issues from a “pooch-like” look in the belly. As fitness professionals, the way we train our clients will either help, or exacerbate, the issue — and we want to ensure you’re doing the former. Read on to learn how to accurately identify diastasis recti, and how to help prevent or manage it with your clients.
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.
Sometimes DR is confused with a hernia. However, DR is just a thinning and weakening of the linea alba tissue, whereas a hernia is when internal contents (intestines or organs) actually protrude through a weak point in the abdominal cavity (or other cavity). Hernias require surgery to address, whereas DR can typically be healed without surgery.
What causes diastasis recti
As mentioned upfront, DR is a “pressure problem” that often happens when the Core Canister is not functioning properly. To explain further, recall that all the abdominal muscle layers (TVA, obliques, rectus abdominis) are connected at the front midline of the body by fascia known as the linea alba (see the left image at the top of the page). If consistent and excessive outward pressure is placed on the linea alba (like from a growing belly during pregnancy), then it eventually thins and stretches out 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 (see the right image at the top of the page).
A growing belly isn’t the only thing that causes excess intra-abdominal pressure. Things like rapid weight gain, breath-holding during exertion (Valsava), chronic “sucking in”, and weak Core Canister muscles can all be contributors as well.
What factors make a woman more susceptible to getting diastasis recti during pregnancy?
It’s important to note that every woman will experience at least some degree of DR during her third trimester of pregnancy when her belly is largest. If managed properly though, it should resolve itself within 4-6 weeks after delivery. However, excessive intra-abdominal pressure can cause the diastasis to remain in the postpartum period, and long beyond. Factors that increase a woman’s likelihood of getting it include:
- Rapid or excessive weight gain (the larger the belly, the more pressure)
- Being pregnant with multiples
- Having a shorter torso (baby has less room to grow, so forces belly out more)
- Forceful “bearing down” during strenuous activity (constipation, vomiting, etc)
- Weak Core Canister muscles
- Core exercises that create excessive pressure like sit-ups, bicycles, leg lifts, and full planks
How to check a client for diastasis recti
Even without checking for it, you may be able to tell a client has it if you see a coning or dome-like shape in her belly during any movement that engages her abs. Look for the bulge to come to more of a point down the center of the abdomen (like the image below). It’s often easiest to see after pregnancy, when the muscles are lax, but you may be able to see it during pregnancy as well.
Watch the video below to learn how to check a client for diastasis. Remember to wait until a woman is at least 6 weeks postpartum to perform the check, as every woman will have at least some degree of separation in the first 4-6 weeks after delivery.
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.
What you can do to help prevent diastasis recti
- Coach her into neutral alignment: Neutral alignment is critical for reducing stress on the core muscles, and pregnancy pulls a woman out of neutral (into the anterior pelvic tilt, and rounded shoulders). Focus on these Neutral Alignment Tips to help your client move better in her daily life, and not just the time she spends with you in the gym.
- Develop optimal Core Canister Function: This is CRITICAL because the muscles of the Core Canister (Diaphragm, TVA, and Pelvic Floor) work together as a pump to dynamically maintain intra-abdominal pressure. In other words, if your client’s “pump” is shut off in any way (as it is with most clients), excess pressure can buildup. Read this Core Canister Article that explains this concept in more detail, and describes how to properly activate the pumping mechanism.
- Cue her to BREATHE (right)! This is also critical, and builds on the point above. Breath-holding shuts off the Core Canister pump, and creates excess pressure. Make sure your client understands how to 360° Breathe, and ensure she’s utilizing this strategy and exhaling on the effort in every single exertion movement she performs (in and out of the gym).
- Avoid spinal flexion/extension (sagittal and frontal) later in pregnancy & earlier postpartum: This goes for exercise and in daily life. All these movements place excess pressure on the outer abdominal wall. The biggest mistakes women make in daily life is slouching (this is spinal flexion), rounding at the spine when bending over, and jackknifing out of bed (crunching up from lying down and vice versa). So in addition to avoiding spinal flexion in your sessions, teach your clients proper movement mechanics (i.e. sitting tall, hinging at the hips when bending over, and rolling to their side first when moving onto their back). The same goes for postpartum women returning to exercise. Their deep core muscles are too weak for these advanced outer abdominal-focused exercises. Begin first by rebuilding their deep core muscles.
- Regress plank-like exercises (later in pregnancy & earlier postpartum): As a woman’s belly grows, it places too much pressure on the outer abdominal wall when in a downward facing plank position – even in the strongest women. Therefore, as her belly grows, you’ll need to begin to regress planks and any plank-like movement (push-ups, renegade rows, etc) — having her place her knees on the ground, then moving to incline planks, then maybe even wall planks. The same applies for postpartum women returning to exercise. Their deep core muscles are too weak for these more advanced movements when first resuming. Begin first with simpler deep core rehabilitation exercises, and work your way up to planks.
- Coach her to avoid “sucking in”: Many women have a tendency to “suck in” when they are in the earlier stages of pregnancy (and have not yet announced it), or when they are postpartum and still have a little belly. However, sucking in shuts off the Core Canister pump, which creates excess intra-abdominal pressure that has nowhere to go but downward onto the pelvic floor muscles, which can lead to diastasis or pelvic floor dysfunction.
- Coach her to avoid “bearing down” during bowel movements: Hormonal changes in pregnancy can cause increased constipation, which sometimes leads to forceful “bearing down.” However, going back to the breathing point above, breath-holding and pushing like this creates a great deal of excess intra-abdominal pressure. If your client struggles with constipation (yes, you may need to ask this), encourage her to place an 8-12” stool beneath her feet when on the toilet to put her body in more of a squat position. This position helps open up the colon to allow for easier waste excretion. You can also provide her these additional tips on minimizing constipation.
- Keep weight gain in check: Rapid or excessive weight gain places more pressure on the connective tissue. Support your client in staying within the healthy weight gain guidelines.
- Always be on the lookout for “bulging:” in any movement your client does, always watch for “bulging” (or that coning that you saw in the image above). If you see this, it is a sign of DR, and that the movement your client is doing is NOT appropriate for her.
What to do if your client have diastasis recti
If your client has DR, and you’ve taken one of our Pre/Postnatal Certification Workshops, or have some other training in this area, you may be able to work with clients who have a mild separation (up to 3 fingers, and moderate depth). However, if your client’s separation is more severe, or if you are not confident in your ability to support her recovery, it is best to refer your client to a physical therapist — specifically a pelvic floor physical therapist, or one who specializes in women’s health. The linea alba can be rebuilt, but it does take time, diligence, and specific rehabilitation exercises. It’s important to address it though, as diastasis will not heal on its own without the proper rehabilitation work, and it could likely be made worse.
Typically the best approach is for a woman to go through physical therapy to correct her DR first, before resuming traditional exercise. If you do happen to work with a woman WHILE she is doing physical therapy, it will be very important for you to understand the work her PT is doing, any specific instructions you should be following, and to adhere to the tips above in prevention.
Interested in learning more? Attend one of our certification workshops.