Diastasis Recti Abdominus (DRA) and Pre/Post Natal Health

What is it?

A Diastasis Recti Abdominus looks like a “split down the middle of the abdomen”.  You will be able to sink your fingers into this widened gap and when doing a curl up, part of your abdomen may ‘dome’ or push outwards.  Your rectus abdominus muscle (the 6 pack muscle people always refer to), has a right and a left side to it.  At the midline of your belly, running between your xiphoid process and your pubic bone is some tissue called the linea alba.  Your rectus abdominus muscles attaches into this tissue.  During pregnancy, there will be a stretching of the linea alba which creates more space between the right and left rectus abdominus muscle heads.

3 finger widening
3 finger widening

It is believed that 100% of women will have a DRA during their third trimester.  Many of these will resolve, many will remain but will present as non-problematic and some will experience continued problems such as a lack of stability, back pain, etc.

Why does this happen?

As the uterus enlarges to accommodate the growing baby, so too does the abdomen.  Although the linea alba has much more ability to stretch in the superior to inferior direction, it has less ability in the side to side position. This results in a lot of stretching through the linea alba and consequently through the rectus abdominus muscle.  Though a DRA is experienced most commonly from pregnancy, both men and women who have gained a lot of weight may have a diastasis recti as well or if they have done a lot of core work without engaging their deeper stability system well.

What can I do about it?

There are DRA’s that cause problems and those that do not.  It is more important to determine whether or not the separation is functional or dysfunctional.

Functional DRA

When you are able to generate optimal tension in the tissues of the midline. Optimal tension is tension generated from your transverse abdominis muscles rather than from your oblique muscles.

Dysfunctional DRA

When you aren’t able to generate optimal tension along the midline, even with helpful cueing and direction.  This is a situation where conservative treatment will be less helpful.

If you have a dysfunctional DRA that is either causing you pain, a noticeable decrease in stability or it bothers you visually, then surgery may be an option.

But what to do with a functional DRA?

This is a situation where conservative treatment should help. Having a visit with a pelvic floor physiotherapist is the first step. During the initial session, a proper assessment can be made to determine the amount of stability around the core or ‘abdominal canister’. The core is primarily made up of:

  • transversus abdominus
  • pelvic floor muscles
  • multifidus
  • diaphragm
The core muscles

You need all these muscles to be in good working condition to help support your body.  It is important to learn how to properly engage your transversus abdominus muscles.  This will ensure that you have an optimal loading pattern when moving around throughout your day.  Less optimal loading patterns are seen when you are using your internal or external obliques too much thereby inhibiting the use of your transversus abdominus muscles.

Over use of internal oblique muscles
Over use of internal oblique muscles

When the inferior angle, the angle between these bottom ribs shown in the picture, is wider than a 90 degree angle, it indicates an overuse of the internal oblique muscles.

Overuse of external oblique muscles

When the infrasternal angle is less than 90 degrees, it is indicative of an overuse of the external oblique muscles.  The above picture shows a lot of compression below the ribs and into the midline of the body.

There needs to be a balance between the external and internal obliques so the transverse band can then do its job. Once you are able to activate these muscles well, different positions can be added in; sitting, standing up, squats and lunges to name a few. Other things that need to be assessed are:

  • an internal pelvic floor assessment is sometimes necessary as your pelvic floor muscles make up part of your core
  • your breathing patterns needs to be assessed to ensure your diaphragm is working well to balance the intra abdominal pressure
  • your deep, low back muscles, the multifidi, need to be assessed to ensure they are functioning well in their supportive role
  • posture, both static and dynamic, as poor posture increases the amount of stress your body will feel

The most important thing to remember is this:

its not what exercise you do … its how you do the exercise

What not to do

While you are working with repairing your DRA, some exercises will not be appropriate.  This is because it takes a lot of work to engage these deep muscles and challenging them too much, too soon will not heal them, but rather, may hinder their repair.  These more challenging exercises tend to increase the abdominal pressure resulting in your belly pooching outwards.  Any exercise that you do where you notice your belly pooching outwards or your diastasis widening, you must stop immediately.  This is not helping.  You must take out:

  • exercises that cause you to curl up (crunches, full sit ups, etc.)
  • exercises where you are lifting a lot of weight
  • taking part in an exercise class where you don’t have enough time to consistently engage these muscles properly before executing a movement

What to do

Learn how to properly engage your deep muscles. Think about exhaling and initiate your exhale using your lower belly, below your belly button, to pull inwards.

With belly relaxed
With belly relaxed
With proper muscle engagement
With proper muscle engagement

It’s important to lift up from the bottom of the belly rather than pull up with the oblique muscles.  In this second picture, there is still a bit too much oblique action, but much better utilization of the lower abdominal muscles during an exhale. This action should then be practiced with everything.  Practice this in different positions and with different functional activities and definitely during exercise. Practice this throughout your pregnancy so you will have the pattern imprinted in your body and accessible during the post natal period.

Maintaining a neutral spine, if possible, during your exercise is best as your muscles tend to work most optimally and with the least amount of undue tension in this position.  Learn this motion first in the above picture, start with small exercises to enforce the proper movement and don’t rush to get back to your exercise class or running too soon.  And remember, it takes time to repair something so don’t be too hard on yourself. For more information please check out https://www.youtube.com/channel/UCJqDcZOOLoNKdBwxmY_wawA

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