Diastasis Recti: What it is, how to test for it, and the keys to recovery

Diastasis Recti

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 to hopefully give you some peace of mind and simple guidance to help you manage or prevent DR from becoming an issue.

What diastasis recti is

In short, diastasis recti (DR) is a separation of the right and left sides of the rectus abdominis muscle (your “6-pack” muscle) due to a thinning and weakening of the connective tissue — called the linea alba — that holds the two sides together.  A small separation is normal, but a separation greater than 2.7 cm (or about 2 finger-widths) is considered DR. 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. 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 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.

The important thing to note here is that some degree of Diastasis Recti is actually a normal and natural part of pregnancy.  Yes, that’s right.  Some 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 please, do not panic if you feel some separation, especially during your third trimester, and do not attempt to “close the gap.”  Your body is doing what it is designed to do.  However, other factors (which we will discuss next) can further exacerbate the pressure in your abdominal cavity 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 increase risk of (or worsen) DR

Basically, anything that creates excessive intra-abdominal pressure will lead to greater risk of DR.  So, when it comes to pregnancy, the larger your belly, the greater your DR will likely to be.  Sometimes this is unavoidable if you are having multiples, or if you have a smaller torso (which leaves less room for baby to grow up and down).  That’s ok, and can be managed (we will get into management tips next).  The following things exacerbate pressure beyond the growing belly, so could increase risk of getting, or worsen, DR:

  • Excessive lower back arch: The growing belly during pregnancy tends to tip your pelvic forward and pull your back into an excessive arch (like in the image below), which places increased pressure on your external abdominal wall and that linea alba (silly puddy) connective tissue, as you can see in the image below:

  • Improper “core” exercises performed with a belly:  Read this post on Core Exercises to Avoid.  All these moves like spinal flexion (like crunching), extension (like back-bends), side bends, full planks, twisting, and more create far too much pressure when performed with a belly, and will almost certainly exacerbate DR.
  • 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 intra-abdominal pressure.  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!

  • Slouching or poor bending over technique: Slouching is crunching (spinal flexion), and so is bending over with a rounded spine vs. hinging at the hips and maintaining neutral. In addition to putting pressure on the external abdominal wall (especially when performed with a large belly), slouching weakens the core canister muscles, so they are not as effective at regulating pressure.
  • Sucking in: OK, we know many of us are inclined to do this a lot — especially in the earlier stages of pregnancy when you may want to hide your belly from your friends and coworkers, or in the earlier postpartum stages when you want to minimize your post-baby belly.  However, “sucking in” (inhaling and drawing your navel in) increases intra-abdominal pressure.  So, ironically, an action many of us take to make our bellies look smaller actually has the opposite effect.
  • Chronically engaging your core: You may often hear fitness instructors cueing you to “engage your core” or “draw your navel to your spine.”  A certain amount of this — if done correctly by drawing in on the EXHALE — is necessary during the more difficult portions of movements.  However, it is NOT good to keep your core chronically engaged.  We tend to hear this cue so often that you may be tempted to just keep your core engaged as a way of making it stronger, but just like sucking in, this has the opposite effect because it essentially “shuts off” your core canister (pressure regulating) muscles, which increases intra-abdominal pressure.  .
  • Breath holding during exertion: Breath-holding during exertion (or Valsalva as it’s referred to) dramatically increases the pressure in your abdominal cavity.  This increased pressure actually creates more power, which is why powerlifters, or individuals doing heavy lifting, often 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 can provide more power to expel the bowel movement. Again, the downside is that it can lead to, or worsen, DR.  Unfortunately, hormonal changes during pregnancy actually increase the likelihood of being constipated.

How to tell if you have diastasis recti

You may notice that torpedo-like protrusion in your belly (shown at the beginning of this post) during any movement that engages your abs. 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.

You can also perform a self-check. We do not recommend doing this until you are at least 6 weeks postpartum. Recall that every woman will have some degree of DR during the third trimester, so it’s not really necessary to check during pregnancy because likely you will have it.  That DR will still be there once you give birth, but will begin to close over the next 6-8 weeks.  This is why we recommend waiting at least 6 weeks to get a more accurate assessment of your true separation.

Watch this video to learn how to perform a proper self-check.  It’s also a good idea to ask your doctor to check you at your postpartum visit.  While doctors should check for this, most unfortunately do not, so you have to ask.

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 severity.  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, does that separation seem pretty shallow and taut?  If so, that’s a good thing, and means it will likely heal faster.  However, if that separation feels soft and squishy, allowing you to sink your fingers down into the gap, this means that connective tissue (linea alba) is more compromised and will take longer to heal.  In many ways, the depth of your separation can mean even more than the width, so check for both.

How to help prevent or manage DR

  • Watch your alignment: Follow these tips to help you Get in Neutral Alignment to reduce the added stress on your abdominal wall and pelvic floor.
  • Keep weight gain in check: It’s important to ensure you gain enough weight for the health of you and your baby.  However, try to avoid gaining too much, as this will lead to a larger belly, which means greater DR.  Follow these tips to stay within the healthy weight gain guidelines.
  • Strengthen your “Core Canister”: When the Core Canister Muscles (diaphragm, transverse abdominis, and pelvic floor) are strong and functioning properly, they act like a pump to regulate intra-abdominal pressure.  We get these muscles to function properly through proper breathing mechanics, or 360° Breathing. If you master this style of breathing, and make it become natural, it’s like doing over 20,000 reps per day of the best core exercise there is.
  • Avoid “aggravating” core work as belly grows: This is an easy one.  Just Avoid These Core Exercises once you develop an obvious belly.
  • Sit up tall and watch how you bend over: Remember, slouching is crunching.  So is rounding forward when you bend over.  So, try to remember to sit up tall.  When you bend over, do so by sending your hips back first and maintaining a long neutral spine as you lower down.
  • Avoid Breath-holding (“Exhale on the Effort”): During your workouts (and in life), remember to exhale on the effort.  In other words, inhale on the easier portion of the movement (like lowering down into a squat, or extending your arms before a row or bicep curl) and exhale on the more difficult portion of the movement (rising up from the squat, or performing that row or bicep curl).  Try to avoid breath-holding on the effort.
  • Avoid bearing down on the toilet: Building on the point above, try to avoid breath-holding during difficult bowel movements (or bearing down).  We recognize this can be difficult when constipated (a lovely side effect of pregnancy). Read these tips to help reduce constipation during pregnancy.
  • Avoid any move that triggers “coning”: Always be on the lookout for that “torpedo-like” protrusion (shown below again). If you see this, it’s a sign that movement is not appropriate. Don’t panic, just stop the movement and find an alternative.

What to do if you have diastasis recti

DR is correctable without surgery, but it often does take a more regimented approach with specific exercises and lifestyle modifications.  You can begin with the exercises listed here in this Postpartum Core Recovery piece.  These exercises can also be done during pregnancy if DR is problematic.  The exercises listed here are an excerpt from the more comprehensive 3-Stage PROnatal Core Recovery Protocol, which has been shown to be very effective in healing mild to moderate DR.  Want to work with an expert to go through our entire recovery protocol?  Consider working with one of our expert PROnatal personal trainers or find a pelvic floor (or women’s health) physical therapist near you.  Physical therapy is especially recommended for those with more severe cases of DR or when you are in a great deal of pain.

Are you a fitness professional interested in learning how to help women heal their DR? Consider taking our education to become a Pre/Postnatal Performance Training Specialist.