This blog has recently undergone a huge overhaul since gathering new research that I will reference throughout. If you'd like copies of any of these papers, just ask!
I have also recorded myself reading this blog because I'm very aware that those that need this information the most, probably have he least amount of time. This way you can listen to the information driving, cooking, walking, at dinner parties... I'll warn you now, I had a very small window to record this while my baby was sleeping, but he woke up half way through. It's definitely not the most professional thing you'll listen to all day but it's easily accessible and that was the objective!
In my new Diastasis Recti (DR) blog, I will be covering the following topics:
Every person’s DR is unique to them and why a "one-size fits all approach" to DR will not work;
When to start rehab for DR after pregnancy and why I don’t usually recommend belly binding;
The essential steps I take when beginning DR rehab with a patient;
One exercise you can start today no matter what your DR looks or feels like.
DR is NOT “a muscle separation”.
DR is the unnatural widening of the NORMAL distance between the left and right parts of your Rectus Abdominus (RA). There is always a gap between these muscles. This is important to take into consideration when you’re rehabbing your DR especially if you’re a perfectionist. These muscles have never and will never “stitch” back together (non-surgically).
And the normal width of this gap varies between person to person. There is no “normal” width.
The RA is really a pair of muscles – twins if you will; each vulnerable to different stresses and loads depending on how you move your body. Which means that one side might be pulling away from the centre, further than its counterpart, depending on the way you load your body.
The other little part of anatomy that is really important to understand is your Linea alba (LA). This is the fibrous sheath that connects these twins down the middle. It connects your sternum (breastbone) and ribcage, to your pelvis.
Incredibly, this sheath also has connections with ALL of your abdominal muscles. All the muscles of your abdomen are weaved together via a strong tendon like structure called aponeurosis, and they merge down the centre becoming the LA.
This way, you have a skeleton-like protection for all your important abdominal organs PLUS the flexibility to do all the things we do without being weighed down by a bunch of bones! Very clever indeed.
So a diastasis Recti is actually a deformation or distortion (no-one really knows) in the LA which allows the two RA muscles to move away from the midline. And because all the abdominal muscle are connected, we have to take into account weaknesses or imbalances in ALL the abdominal muscles allowing for this VISIBLE change to be occurring at the front. This is going to differ between every single person because we all load our bodies differently. That is why there is no successful "one size fits all approach to repairing a DR".
Every person’s DR is unique to them.
Not all DRs are made the same.
Where is your DR? And where is it worst? At your belly button, below or above it? This will obviously determine which muscles need to be better recruited.
Is your DR narrow but really squishy?
Is your DR wide but really firm?
Do you get doming (when your abdominal contents push out of the gap)?
Does your DR pull to one side?
For an example:
Do your ribs flare out on your right side? That means you’re not recruiting your external obliques on the right which will be pulling your LA to one side. If so, then you will need specific exercise for your right external oblique. Simples. Almost.
WHY has your right external oblique gone to sleep? If we don’t fix that, then you can do as many exercises as you like, it’s not going to go away.
So some people can jump straight into planks and crunches safely, because that’s exactly what THEY need to heal THEIR DR. Whereas for another person, that would make them so much worse.
This is why it is so important when starting your DR healing journey to see a professional that’s trained in assessing DR so that you get the right solutions for you. They can tell you;
Where you’re too tight;
Where you’re too weak; and
What you’re doing in YOUR life that’s contributing to your imbalance and DR.
I repeat, this is why a “one-size-fits-all” approach to DR will not lead to optimal or lasting results.
DR is a whole body issue.
So all we have to do is find out which of our abs are weak and strengthen them? Sadly no, let me explain. Because of the way that the LA attaches to the rib cage and pelvis as well as all your abdominals, pretty much ALL motions of your body impact the load placed on your ALL of your abdominals.
STUDIES SHOW that weight gain, size of baby and abdominal circumference is irrelevant for having a DR at 6 months post partum (not including twins). So what’s the deal? If it wasn’t the gigantic baby pushing my abdomen apart, what gives? #punalert
Fernandes da Mota, P. G., Pascoal, A. G., Carita, A. I., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy, 20(1), 200–205.
The way you stand, the way you sit, the way you reach up above your head, the way you lift, the way you lean onto the centre console when you're commuting to work 2 hours a day, the way your cross one leg over the other, the way you sleep, the way you carry your toddler on one hip, the way you exercise, – all of these things impact the movement of your pelvis and rib cage and in turn impacts the forces applied to your abdominals. That’s without the force of a baby pushing your abdominals out from the inside, which is why even people who have never been pregnant can acquire a DR. BOOM.
Maybe you’ve been a hairdresser for many years and you’ve asymmetrically strengthened your abdominals to support your blow-drying arm whilst simultaneously hanging out on the other hip because you’re on your feet for many hours of the day and you're tired. This imbalance is going to create a chronic deformation force on your LA.
"DR is just a symptom of poor mechanical function of your entire body."
Katy Bowman
Add a pregnancy to that body and the pressure in your abdomen has to go somewhere. Out the front, like a form of herniation. But that’s not the case for everyone because (as unfair as it is) some people just have genetically stronger fascia and connective tissue.
So lifestyle and postural modifications make a huge difference to the way you load your abdominals that will help correct it all day long. This is arguably much more important than the 30 minutes of exercise you do 3 times a week.
Doing “exercises” without changing the habits that caused your DR in the first place is like eating MacDonalds all day then eating a salad for dinner. So if you’re like me and not a “gym person” you can still get great results.
Actual footage of me in the afternoons trying to figure out what to cook for dinner.
I give you this information because I want to plant a seed in your mind. You’ll start catching yourself typing and reading a document that’s resting on the left side of your keyboard for hours (as I am now, time to switch sides and uncross my legs!!). You’ll start to identify the ways you place asymmetrical loads on your body and hopefully, make a change. This is the best thing you can do to start your DR healing journey and have lasting results. This is information you’ll never “un-know”. And the good news is, you can start this immediately! Whether you’re trying to conceive, 36 weeks pregnant or 75 minutes post partum.
Heels & DR.
This is a touchy subject for me. I love wearing heels on special occasions and I wore them on such occasions during pregnancy.
Heels sometimes, no heels every other time.
But wearing shoes with a heel everyday while you’re pregnant (and heck, anytime in your life) is a huge contributing factor to DR and many other body ailments. Wearing a shoe with any heel causes you to tip your pelvis forward to keep yourself from falling flat on your face. With your new awesome knowledge of the LA and it’s attachments, can you see how this would create a constant strain/pull and eventual deformation of this tissue. You’re basically walking downhill all day long.
If you’re going to a function and you’re wearing a dress and makeup and eye lashes, wear the heels. But every other day, opt for a minimal/barefoot style shoe. Or be like me and occasionally take your shoes off at work – maybe not.
When to start Rehab for DR after pregnancy.
LIFESTYLE CHANGES, BREATHING AND MOBILISATIONS CAN HAPPEN STRAIGHT AWAY. But when it comes to exercises, give your muscles (that have been stretched considerably) time to heal. Pregnancy stretches and thins the RA so don't do too much too soon, give your anatomy time to repair and return to a normal thickness, then strengthen.
DID YOU KNOW, some studies suggest that DR is could serve a purpose initially post partum. It could be the body’s way of taking the abdominal pressure off the pelvic floor while it heals after childbirth. The study showed that women with DR were NOT more likely to have prolapse and more women had prolapse at 6 weeks post partum that DIDN’T have DR! This is why I don’t recommend binding or corset type belly bands post partum unless there is a severe DR and we want to prevent hernia.
Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics, 36(3), 716–721
What are the consequences of DR?
There aren’t any good studies to support a direct correlation between low back pain and DR (If you find one please send it my way!) However, in my practice and with my knowledge of anatomy, I can easily see how a poor functioning support system for your pelvis and spine contributes to compensations around the body leading to aches and pains, early wear and tear of joints being over used and nerve impingement from muscles doing work they’re not designed for.
One example is:
A poor functioning core will change the orientation of your pelvis. This will change the muscles you recruit to walk. Now you’re using hip muscles instead of your glutes. These muscles will get tight and sore and then press on your sciatic nerve giving you deep butt pain. Ever wonder where your butt muscles went after pregnancy? Yes, mumbutt is a thing. They didn’t go anywhere! They’re just asleep because you never use them anymore due to the new orientation of your pelvis due to pregnancy.
Other than low back pain, other issues I have observed are:
Increased risk of prolapse;
Herniation of the umbilicus (belly button);
Increased susceptibility to symphysis pubis dysfunction (pain at the front of your pelvis) during pregnancy;
Inefficient contractions in labour as the uterus is lacking a strong wall to push against. This can lead to longer more tiresome births for mother and baby;
A bra or top size that just won't go back to normal despite weight loss;
Tailbone pain;
Low back pain;
Pain during intercourse; and
The dreaded “mum pooch” or a lower abdomen that makes you look as though you are still pregnant.
What am I doing now to make it worse?
Sitting straight up from lying down. Shimmy your pelvis to one side, roll yourself onto one hip then push yourself up with your arms;
Using repetitive postures or using one side of your body more throughout the day eg. carrying your toddler on one hip all day. I know it feels weird but swap sides every now and then;
Constantly sucking your tummy in;
Constantly clenching your bum or jaw - check, you might just be doing it now;
Heavy lifting (or not correctly bracing your abdominals to prepare);
Abdominal exercises that recruit the wrong muscles for your DR;
Shallow breathing that either lifts your chest or pushes your belly out with inhalation;
Constipation and other forms of straining. DO NOT STRAIN TO POO…EVER; and
Even sitting from standing if you aren’t engaging your core properly!
The essential steps I take when beginning DR rehab with a patient.
I will:
1. FIX YOUR BREATHING
If you aren’t breathing properly, your ribcage is stiff and you aren’t managing pressure within your abdominal cavity optimally. It is the MOST important place to start your rehab. You do it all day, everyday. See my Blog "Breathing. The first and vital step in post-partum recovery" to find out more about the ill-effects of a poor breathing pattern.
2. FIX YOUR POSTURE
All we do is sit, sit, sit. And it's seriously bad for us. Let's forget about all the wrong muscles you're using and all the useful ones that are switched off for now. The slouching/crunched posture stiffens our upper backs, pushes our necks forward and creates so much increased pressure into our abdomen and pelvic floor. This alone makes it very difficult for the abdominals to function appropriately to facilitate healing.
DID YOU KNOW that the muscles of the abdomen are innervated by nerves that exit the lower thoracic spine. So if you have stiffness in that area from slouching or sitting for long periods (or only doing bent over rows at the gym), could this be impacting the healing of your DR?
Thanks to all this sitting, we've also forgotten how to stand! We chronically suck our abdominals in, clench our butts, hang forward in our hips; all of which are straining our LA (Linea alba in case you've forgotten). We need to identify these habits and kick them to the curb!
Like breathing, your posture is likely something you adopt all day. Remember that MacDonald's binge I mentioned earlier.....
3. STRENGTHEN SPECIFIC MUSCLES FOR ALIGNMENT
Do you have weak glutes that make your hip muscles grip all day long that leads to deep butt pain? Do you have hip bones that are sitting too far forward in the hip socket? Are you overzealous with your quads and hamstrings? Are your shoulder blades winging away from your ribcage? What about your pelvic floor? Is it too tight or weak or both?
Have you ever noticed your urinary incontinence to get worse the more Kegels you do? This might be because your pelvic floor is too tight. When it is too tight, it can’t work properly and therefore becomes weak. If this is you, you might need to do pelvic floor release and lengthening first before you do any strengthening. I can do this for you but if it's really tight, I may have to refer you to a pelvic floor physio who can do internal release work for you. There are plenty of home release strategies you can try at home too.
4. BALANCE YOUR ABDOMINALS
All your abdominals need to work in harmony for optimal strength, alignment and pressure management. Identify what needs strengthening and what needs to be rested and progress from there.
DID YOU KNOW Chronic sucking in over-activates your middle Transverse abdominus which INCREASES the pressure outward in your lower abdominals which can contribute to lower belly pooching! And worst case increase pressure on your pelvic floor which can lead to prolapse. So let that belly hang out!
5. FIX YOUR ARCH STRENGTH…YES, IN YOUR FOOT!
If you have poor arch strength, this changes the way you walk. You actually need more force to propel yourself forward. This increases pressure in your abdomen with every step you take!
6. TREAT ALL THE TIGHT STUFF SO YOU FEEL BETTER AND CAN ACTUALLY DO YOUR EXERCISES.
The heading just about says it all. If your body is too still you can't do your exercises properly. And getting into some of those tight spots can make you feel amazing!
Why, when and how to check your own DR.
WHY.
In my practice, I ask every woman who is pregnant or has ever been pregnant if they have a Diastasis Recti. The most common response I receive is “No, I was checked in hospital when I had my baby and it was all good.” Or even worse; “I have no idea, no-one has ever checked me.” This is incredibly frustrating to me. Especially if it turns out that she actually has a significant separation when I check her. Let me explain.
Once your baby has been delivered (regardless of the mode of delivery), it feels as though someone has removed a giant concrete brick from underneath your rib-cage. All of a sudden you have the ability to do amazing things. Like bending over to put your undies on or sit up in bed without having to shimmy one hip across before gracefully flinging one leg off the bed, hoping that (thanks to it’s momentum), the rest of your body will follow through.
So we DO start sitting straight up again, we bend and lift and push like no baby was ever there. Not only that but we now have an actual baby. A baby who cries and needs to be rocked. A baby who is growing heavier by the day. A baby who travels in a car capsule that weighs more than your golden retriever. And it doesn’t stop there. That baby turns into a toddler who spends most of their waking hours perched on one of your hips so you can actually get anything done! *Deep breath*
My point is, after birth is when your abdominals really have to start working. If there is an un-diagnosed Diastasis Recti because it was never checked properly or you had a slight widening and was told not to worry about it – can you see how getting on with life without a care in the world can lead to a worsening of that innocent situation?
WHEN.
Now that we know that it doesn’t take a baby to take over your innards to cause a DR, check NOW. You don’t have to have ever been pregnant. It’s also a sensible idea to benchmark your LA so that later, you know what it felt like before having kids. Check in your first trimester. It literally takes 1 minute of your time and can be done when you get into bed at night. Then check again in second and third trimester. Ask someone to check it after you’ve given birth and check it again 3 weeks later and again 3 weeks after that.
HOW.
The first thing to look out for is that bulge that sticks up vertically in your abdomen when you go to sit up from lying down. We call this “doming” or “coning”. Often women have noticed this themselves but had no idea what it meant. It means you have a weakening in the fibrous sheath that supports all the muscles in your abdomen and it’s allowing your abdominal contents to poke out between your two RA muscles! (But you knew that already.)
This is extremely important information in beginning your rehab but also gives us great feedback when progressing into harder exercises.
Start by lying on your back on the floor or a mat with your knees bent or straight – just be consistent with your set up from now on;
Place the fingers of one hand on the midline of your abdominals, about two inches above your belly button. Your fingers must be flat and pointing down towards your pubic bone;
Press those fingers into your belly slightly;
While holding that gentle pressure, lift your head off the floor or mat just enough to feel your muscles engage;
Feel the border of the muscles squeeze against your fingers and work out how many fingers fit between the two sides snugly. Write that down so you can track your progress;
Now measure how deep your separation is. To do this, just note how deep your fingers sink into the gap. Is it just the tips of your fingers, past your nail-beds, past your first or second knuckle? Write this down too;
Lastly, feel how firm that gap is. Is it squishy or firm? It should feel like a springy trampoline. Do your fingers meet some resistance or do they sink down into softness? Yes, write it down. This is incredibly important information and changes your exercise needs dramatically!
Now repeat these steps at the level of your belly button and 2 inches below recording your width, depth and squishiness/firmness.
I really have no idea why this woman is smiling. If you look closely, she has doming of her abdomen which means her abdominal contents is being pushed out. She's not managing pressure safely and is putting herself at risk of prolapse, stress urinary incontinence and poor lumbar stabilisation. And the worst part is, someone told her she's doing something good for herself. "Unfortunate mislead lady, stop what you're doing immediately!"
One exercise you can start today no matter what your DR looks or feels like.
Learn to breathe.
I sound like a broken record at this point but it really is the best place to start because it influences which muscles you recruit when and is the foundation for all your rehab exercises going forward.
For a muscle to become strong, it needs to be lengthened appropriately so it can contract in its full range. If a muscle is constantly contracted and tight, over time it becomes weak. This is the case for the pelvic floor and abdominals when you don’t breath properly. They should be lengthening and contracting all day long. And if you’re shallow breathing, they are missing out of the vital movement they need to do their work.
Not only that but as a result of this type of breathing, the wrong muscles are utilised which leads to weakness, pain and discomfort in your neck, shoulders, jaw, head, hips, butt and low back.
Some people think they are very clever and try to outsmart me by doing a big belly breath. Yogis, I’m looking at you! But this can be even worse for a DR. All that pressure is going to go down the path of least resistance and if you have a weakened LA, where is that pressure going to go if you let it? Out the front. Side note: Sometimes if someone has been a chest breather all their life, getting them to breath into their stomach first might be the only way to get the breath downward. Then we work on moving it to the ribs later.
So! We want our breaths-IN to be expanding in a 360 degree way. Expanding our ribs out to the sides, expanding our backs, creating gentle pressure down to lengthen our pelvic floors and a little into the abdomen. Sometimes it’s been such a long time since we’ve breathed in this manner that it takes a little bullying. (The only arena where I condone bullying.) Remember when I said that your breath will follow the path of least resistance? Well creating pressure in areas the breath usually goes, will force it into areas it should go but has been avoiding. Let me show you!
Back expansion with inhalation.
You can do this in a full squat with your knees against your chest or lying over an exercise ball, foam roller or rolled towel.
As you inhale, visualise the breath moving into your low back and feel your back expanding then relaxing softly with your exhale. Sometimes the movement is very subtle so it can be helpful to have a partner place their hand on your low back and provide feedback as to whether they can feel your back moving at all.
Once you’ve mastered that, see if you can get your breath low enough to feel it nudge your tailbone.
Side rib expansion with inhalation.
Sitting on a chair with your legs down or on the floor with your legs bent to one side. Reach your opposite arm over head so it’s pointing in the same direction at your legs (if you’re on the floor). Place your other hand on the lower ribs of the arm that’s over your head. This is sounding so complicated, I’ll video it for you, but for now let’s press on. As you breathe in, try to get your breath to expand the ribs under your hand. You can slightly lean forward to get more pressure into the front to avoid the breath going forward.
Now watch yourself breathing in the mirror. Is your breathing moving your chest up or making the muscles in the front of your neck to pop out? If so, stop it immediately! Is your breath expanding your ribs out to the side? Excellent, gold star.
While you’re learning your new breathing style, I always recommend setting a timer to go off every hour (during your work hours) for a week. That way you can regularly check in with yourself and make corrections when need be.
Final thought.
My final thought is patience. It takes time for you to change postural habits you've been doing all your life. It takes time for you to mobilise your body so that you can do the exercises properly. It takes time for your muscles to adapt to exercise so you can progress to harder exercises that bring it all together. And lastly, it takes time for fascia to remodel - over a year when in the right environment. So be consistent with your rehab as well as kind and patient with yourself and luckily, every step of the way you’ll see improvements in the way you look, feel and move.
Some changes will be really quick and some will take time, just remember that this isn’t just about the way you look now, it’s about how your body will cope with stress for the rest of your life.
So in the end, there’s good news and bad news. The good news is, there is a solution for even the widest, fist eating DR. The bad news is, there just isn’t a quick fix. It takes the right guidance, consistency and time!
Love in sharing knowledge, Nadine xx
Image 1 by @iamannelti, image 2 by pelvicguru, image 3 by Zoe Young, image 4 by zainabmughalarts image 5 by by@rowansterenberg, Image 6 from Pinterest, image 7 by @Kelly Colchin Image 8 by deliciously fit and healthy.
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