Diastasis of Rectus Abdominis Muscles

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What Is Diastasis recti

Diastasis recti is a separation of the rectus abdominis muscles located in your abdomen. The right and left rectus abdominis muscles run up and down from your rib cage to your pelvis and are joined to each other by a strip of tissue called the linea alba. Diastasis of recti abdominis muscles (DRAM) is defined as a separation of the two rectus abdominis muscles along the linea alba.

Review anatomy for rectus muscles

The anterior abdominal wall consists of the abdominal rectus muscles separated by the linea alba, which is a fusion of the external and internal abdominal oblique muscle and transversus abdominis aponeuroses. The abdominal muscles are covered with fascia. know this is a lot know that the abdominal wall is made up of more than one muscle because studies indicate the transversus abdominis may also play a role in diastasis recti.

rectus diastasis
Thank You Dr Placik

In the image above you can see separation of the rectus muscles. The pictures on the left side are before and after surgery. The next set of images shows that patient rotated. The gap between the rectus muscles is clearly visible.

What Causes Diastasis Recti?

There is still no consensus about the factors that may lead to diastasis recti.

It is thought to be due to several factors that increase intra-abdominal pressure. The abdominal fascia can become thinned due to stretching, which can be caused by pregnancy and obesity, or prior abdominal surgery.

During pregnancy hormonal changes and the uterine growth may stretch the abdominal muscles, mainly the rectus abdominis muscles. The hormone relaxin is produced by the ovary and the placenta which helps make room for the growing baby. It relaxes the ligaments in the pelvis and softens and widens the cervix.

The bottom line is that it is unclear if the protrusion of abdomen is due solely to laxity of the linea alba or if other factors affecting the abdominal musculature also contribute.

There are probably several factors that occur in pregnancy that lead to separation of the rectus muscles along the linea alba.

Pregnancy is a common cause of diastasis recti but it can also be caused by other factors such as  rapid weight gain and even heavy lifting.

When I did abdominoplasties I noticed that there appeared to be weakness of the entire abdominal wall, not just the center. Other plastic surgeons have noticed this as well.

It is important to note that I have seen the abdomen protrude in patients with no diastasis  and have noted a diastasis in women with flat bellies.

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What factors were associated with

diastasis?

A higher prevalence of diastasis recti was found in women who were older in age, twins, those women who also developed weak pelvic floor as well and those with recurrent caesarian section.

Turan V, Colluoglu C, Turkyilmaz E, Korucuoglu U. Prevalence of diastasis recti abdominis in the population of young multiparous adults in Turkey. Ginekol Pol 2011; 82:817.

Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:321.

It is worth noting that obesity would be expected to increase the risk of diastasis however there are few studies specifically documenting obesity as a risk factor.

Is the diastasis of the rectus muscles worse

above or below the belly button?

Diastasis of the rectus muscles usually is worse (wider) above the belly button

What is considered a normal separation of

the rectus muscles?

There is controversy regarding what constitutes a normal distance between the rectus muscles, at what level  should measurements be taken, and by what means.

Any separation more than 2 cm between the rectus muscles is thought to be abnormal.

The Beer classification established the normal width of the linea alba at different locations of the abdomen. These measurements are 15 mm at the xiphoid, 22 mm 3 cm above the umbilicus, and 16 mm 2 cm below the umbilicus.

How common is diastasis recti after birth?

Research from the University of Oslo in 2016 found that 45.4 percent and 32.6 percent of women have    diastasis recti at six months and 12 months postpartum, respectively.

reference http://bjsm.bmj.com/content/early/2016/06/20/bjsports-2016-096065.full

The prevalence of diastasis of the rectus muscles was 100 percent at gestational week 35 and decreased to 39 percent at six months postpartum. Prepregnancy body mass index (BMI), weight gain, baby’s birth weight, or abdominal circumference was not different between women with and without diastasis at six months postpartum.

Women with diastasis at six months postpartum were not more likely to report lumbo-pelvic pain compared with women without diastasis.

Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20:200.

Problems associated with diastasis recti

How does diastasis recti affect function? Rectus abdominis diastasis may or may not be associated with symptoms. Excessive abdominal muscle separation can compromise the function of the anterior abdominal wall.

We know that a  decline in core function can significantly affect the ability to transfer forces throughout the body. The abdominal wall is crucial for body posture, trunk and pelvic stability, respiration, trunk movement, and abdominal visceral support

Severe diastasis recti may lead to altered trunk mechanics, impaired pelvic stability, and changed posture. Not everyone will develop this, as I noted above.Some women do not notice a difference in function or pain when they have a diastasis of the rectus muscles.

Diagnosis of diastasis recti?

When a patient with diastasis of the rectus muscles raises his or her head and begins to sit up, the increase in intraabdominal pressure as the two rectus muscles contract can result in a bulge from the xiphoid down the center of the abdomen.

Lie on your back with your knees bent and your abdomen easily visible. Place your fingers together in the center of your abdomen. Lift your head and shoulders off the floor as if you were performing an abdominal crunch or sit-up. While carefully holding the lift feel for a gap in between the rectus muscles. Check both above and below your

If you feel a step off or hole in between the rectus muscles, it can indicate a hernia. Hernias are more common in women who have had surgery on the abdomen.’

Some studies advocate using calipers to measure the diastasis recti.

Imaging such as ultrasound and CT scan of the abdomen can also help define the distance in between the rectus muscles. This is usually not indicated and we should try to avoid unnecessary radiation exposure from the CT-scan when we can

Separation between the rectus muscles narrows significantly immediately after childbirth, most women who have a gap eight weeks following pregnancy still have it a year later.

Treatment of the diastasis recti

diastasis rectiConservative management with weight loss and exercise are advised as a first-line treatment

  1. Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg 2014; 48:163.

Post-partum diastasis recti

The Tupler technique is  nonsurgical method of correcting or improving diastasis recti. A binder is worn to allow the damaged connective tissue to repair. The binder is thought to help with off loading. The program typically takes 18 weeks and modified exercise programs are initiated at six weeks.

The small study listed on the website included 8 pregnant women who exercised and 10 women who did not exercise. There was no mention of other factors such as age and prior athletic performance.

Peer reviewed publications are lacking (Up To Date 2017).

Here is a binder that can be worn after delivery Abdominal Binder Waist Trainer, Waist Trimmer, Support Post-Operative, Post Pregnancy And Abdominal Injuries. Post-Surgical Abdominal Binder Comfort Belly Binder (Small (30″ – 45″), 12″ High)

Can exercise help reduce the incidence of

diastasis recti?

Exercise alone appears to help decrease the incidence of diastasis recti.

Exercise programs can be used to help regain some degree of strength in the midline  and closure of the diastasis recti in the postpartum setting. In a randomized trial, 50 pregnant women were randomly assigned to a postpartum exercise protocol or no exercise in the immediate postpartum period. The intervention group had a greater mean decrease in the rectus separation compared with controls.

Mesquita LA, Machado AV, Andrade AV. Physiotherapy for Reduction of Diastasis of the Recti Abdominis Muscles in the Postpartum Period. Rev Bras Ginecol Obstet 1999; 21:267.

Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 2014; 100:1.

What exercises can help with diastasis recti?

Beginner exercises for diastasis recti

Belly breathing-Isometric abdominal wall muscles for diastasis recti

  • Lie flat on your back on the floor.
  • Take a deep breath allowing your chest to fully inflate.
  • Slowly and forcefully exhale while drawing your abdominal wall toward your spine and hold for 10 seconds.

Heel Slides for diastasis recti

  • Lie flat on your back on a mat, with your knees bent and feet flat on the floor.
  • Deep a deep breath in and engage abdominal muscles by pulling them up towards the chest and back to the spine.
  • Exhale and slowly extend one leg out in front of you, letting your heel skimm the floor or for a harder exercise let it hover a few inches above the floor. Alternate sides
Moderate exercises for diastasis recti

Heel slide with foot off the floor.

Cat cow pose for diastasis recti

Cat and cow are yoga poses that engage your core.

  • Get on all fours. Your hands under your shoulders and knees under your hips.
  • Take a slow deep breaths.
  • Arch your back up engaging your core. You should pull your abdominal muscles up and in towards your spine.

Advanced exercises for diastasis recti

Squats or squats againist the wall

The idea of engaging the abdominal muscles during these exercises allow the abdominal muscles to work together to help strengthen the whole abdominal wall, not just the rectus muscles.

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What is the best exercise for diastasis recti

There have been no large long term studies showing that one type of exercise is better than another for improving diastasis recti.

What exercises can make diastasi  recti

worse?

Exercises like crunches, planks or sit-ups may actually worsen the diastasis of the rectus muscles. Any exercise that increases intra-abdominal has the potential to make a diastasis worse.

NMES (Neuromuscular electrical stimulation)

diastasis recti

Neuromuscular electrical stimulation (NMES) is the application of electrical current to elicit a muscle contraction.

Prior studies have shown that neuromuscular electrical stimulation (NMES) has increased abdominal strength by about 14% to 22%.

One study with 60 participants showed improvement in diastasis recti and abdominal wall muscle strength when neuromuscular electrical stimulation is added to a post partum exercise program.

Interestingly the exercises chosen included sit-ups which has the potential to increase intra-abdominal pressure according to the article, “Based on the literature, there is no golden standard exercise program for DRAM; so the following proposed one included sit ups, reverse sit-ups, reverse trunk twists, and U-seat exercises.”

Kamel DM, Yousif AM. Neuromuscular Electrical Stimulation and Strength Recovery of Postnatal Diastasis Recti Abdominis Muscles. Annals of Rehabilitation Medicine. 2017;41(3):465-474. doi:10.5535/arm.2017.41.3.465.

Abdominoplasty to repair diastasis recti

Diastasis recti is often corrected when an abdominoplasty is performed. An abdominoplasty will include removal of the lower abdominal tissue which may give you the a roll.

The the skin of the anterior abdominal wall is undermined up to the xiphoid to expose the fascia of the rectus muscles

The umbilicus stays in its native position and a new orifice is made to accommodate it after advancing the abdominal skin down down over it.

The diastasis is repaired by suturing the fascia over the rectus muscles, this will close the gap.

Drains are used to collect the fluid under the abdominal flap for the first week or so after surgery.

No exercise is allowed for several weeks after the procedure.

An abdominal binder may be prescribed to help compress the abdominal tissue.

How soon after birth should you start

exercises for diastasis recti?

Always check with your physician but usually you can start beginner gentle exercises  such as isometric exercises soon after vaginal birth and perform them daily.

You will have to wait several weeks after a cesarean delivery. You will be sore and doing too much will increase your risk of a hernia.

Lying down and getting up can increase the

intra-abdominal pressure

  • Try to avoid increasing intra-abdominal pressure when lying down or getting up.
  • Sitting on the side of the bed
  • Pull your belly button back to your spine and then lay down on your side.
  • Place your head down on the pillow while on your side.
  • Contract your belly again as you roll over onto your back.
  • Reverse the steps to get up out of bed.

What do you think of diastasis of the rectus muscles?

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About Sharon T McLaughlin MD FACS 236 Articles
I am a physician who is interested in providing health information and health tips so that we may live healthy lives.

18 Comments

  1. I really enjoyed this one! Question for you…..Can one develop this after menopause? I was always thin and after pregnancy had a little puff of a belly. But in the past year I’ve gained 20 pounds all in my belly area. I’ve seen doctor after doctor and their findings are “maybe its gallstones? Maybe it’s a slight hernia? or maybe it is diverticulitis. This after cat scans, colonoscopy, virtual colonoscopy and then some. I wish you were my doctor 🙁
    -Donna

    • You can develop a diastasis with weight gain. If there are no gastrointestinal changes such as upset stomach, feeling full while eating small amounts, reflux, or change in bowel habits it may simple be menopause. Menopause is more likely to be the cause of the weight gain. Our metabolism slows down and women seem to gain more in their abdomen. The fat can be on the outside but it can also be on the inside referred to as visceral fat which can appear as a puffy abdomen. These articles may helphttp://weightlossinwomenover50.com/menopause-weight-gain/ andhttp://weightlossinwomenover50.com/lose-belly-fat/ Ensure you are seeing your doctor for any gastrointestinal complaints and also are up to date with pelvic sonograms with your OB/GYN. You can start weight training 2x along with 30 minutes of cardio a day. More whole grains which can fill you up and less processed foods can make a real difference.

  2. Hi Dr. Sharon,
    I had never heard of this diastasis before. Like Donna I too have gained weight in my later years right around my waist. Good old Menopause. I will take the advice you mention above for myself. Very nice Video on your site.

  3. Hi,

    An interesting article thanks. I hadn’t heard about diastasis recti before, so I learned a lot from reading it. I was surprised to hear that while some exercises can help, others can worsen it. Useful to read which those are.

    Joy Healey – Blogging After Dark

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