“Why Diastasis Recti Experts Disagree: And What This Means for Your Postpartum Belly”
Table of Contents
Dear Reader (that’s you),
Are you wondering what the heck happened to your belly? Are you overwhelmed by the voluminous, yet conflicting internet advice? Can you distinguish an expert from a fauxpert? Are you ready to give up, wear a mumu, and stuff your face with ice cream; or, are you spending hours trying to crunch, plank, and transverse abdominis pulse your way to awesome abs? Are you sick of all my questions? Point taken.
I wrote this for you, which means I wrote this for me because I am you. Not in a weird sci-fi sort of way, but in an OMG WTF happened to my belly kind of way.
Before getting pregnant with the first of my three lovely (and large) children, I had annoyingly rhapsodized about pregnancy’s charm, about how I would love gaining weight, about how rotundity might be a nice change of pace. Ugh. I would like to get in a time machine and laugh heartedly at my pre-partum naïveté.
I didn’t realize that gaining weight during pregnancy would mean replacing my tiny belly with a ballistic missile. Even as my belly grew and grew and GREW, I thought our bodies were magical beings that knew how to spring back into position once the baby blissfully and easily exited our primal forms.
Silly Meredith of the past. After my missile launched, I looked downward and thought “Huh, that doesn’t look like my belly.” I was sure Mother Nature just needed more time to shrink me. A few months later, I thought “Why won’t it go back to the way it was before?!” A few months after that I thought “I will fix this!!”
Thus, an obsession was born. The obsession has evolved over the years as I’ve worked on my body image in concert with my body; however, although diverted, the obsession remains—a search for perfection replaced by a search for information. Therefore, Dear Reader, let me take you on an esoteric journey into the heart of your diastasis recti.
Ever your humble guide,
WHY WRITE THIS ESSAY?
The internet is a torrent of postpartum belly advice, and “diastasis recti” has become the en vogue buzzword. In 2010 when I had my first child, I had to poke around the interwebs to figure out what was going on with my mushy, bloated, gaped, alien belly, but now any new mom can easily find the term and pinpoint it as the cause of her “mummy tummy.” She’ll also be offered half a dozen programs for fixing her belly, some of which are actually quite good, and some (ahem) that aren’t. I know because I tried them all.
The diastasis recti and postnatal fitness world can be summed up in one word: Overconfidence.
“Gods of the gaps” is a particularly apt (and punny) explanation. The phrase refers to a type of logical fallacy, but it also applies to the women’s health world; in the absence of good evidence, many self-proclaimed experts make up their own theories. This is because the theories about closing diastasis recti abdominis (DRA) are not backed by a lot of concrete evidence. No advice giver can be faulted for skimpy evidence. But, they can be faulted for cloaking their evidentiary blind spots. Keep in mind, not all the theories are bad, but some are more plausible than others.
Practitioner overconfidence can lead women down the wrong path or oversell expected results. In extreme cases, overconfidence may also prevent women seeking appropriate specialists, or, in milder cases, may encourage unnecessary physical restrictions.
We know more about diastasis recti every day, but we don’t have any good studies proving the efficacy of any particular approach or exercise routine. Additionally, even those at the research forefront have a theory to defend, money to be made, a horse in the race. This doesn’t disqualify, but it should embed a bit of skepticism in your brain.
As a result, many of the well known DRA experts disagree with each other. This is confusing for us moms. They are confident in their correctness. But, logically, they shouldn’t all be.
This essay differs from other diastasis recti resources because it is a modality review from the perspective of a semi-educated and always skeptical patient. I offer suggestions on how to narrow a diastasis recti, but I try my hardest not to oversell the solutions. We like halcyon answers and precise paths, which means a DRA primer will never out sell a DRA “program.” I’m okay with that. Ambiguity isn’t sexy, but it’s honest.
WHY SHOULD YOU LISTEN TO ME?
Good question. I’m not a physical therapist. I have a personal training certification from the American College of Sports Medicine, but that means squat about my knowledge of diastasis recti. I also have a graduate degree in English Literature, which tells you I wear glasses and read a lot, but not much else. I did narrow my gap and strengthen my abdominals, but not by following a specific program. Plus, you shouldn’t rely too much on any one person’s experience. Take my qualifications for what they are.
Ultimately, I am a slightly obsessive mom who has been trying to navigate this confusing terrain. I’ve tried the programs. I’ve read the experts. I’ve read many of the studies. And I’ve parsed and arranged the evidence into a clear(ish) guide.
I don’t advocate or dismiss a branded program. Therefore, I do not mention the programs by name. Instead, I describe schools of thought and things to look for when evaluating diastasis recti advice. Occasionally, I link to motherfigure.com blog posts that address some of the topics in more detail. Program names may be mentioned in those posts, but I refrain in this essay.
WHAT ARE YOUR GOALS?
I also make some assumptions about my reader, about you. I assume you want to close your gap and flatten your belly. Before we go any further, I must announce a gap isn’t always a big deal absent functional problems, and DRA doesn’t prohibit a flat belly. Conversely, a closed gap doesn’t guarantee a trim midsection. Your diastasis recti may close. It may not. You may get a flat belly by narrowing the gap. You may not.
For example, a study in the journal Plastic and Reconstructive Surgery looked at 92 abdominoplasty patients and found “contrary to current thought, abdominal wall protrusions are caused by the stretching of the entire abdominal wall and not only the linea alba. Thus, significant abdominal wall protrusions may occur without diastasis and flat abdomens may exhibit a diastasis.”
Be careful not to interpret this as saying your DRA has no affect. It probably does. But, sometimes you can sufficiently strengthen your muscles and reduce adipose tissue (a.k.a. fat) to get measurable aesthetic improvement without fully closing the gap.
As a result, we should reframe the goal. The goal isn’t closing DRA (possible for some, but not for all). The goal is a stronger core that stabilizes what needs to be stabilized, that moves what needs to be moved, and that doesn’t balloon out in the process.
I wrote this essay for my 2010 self. I can’t go back in time and read it, but hopefully I can help some of you evaluate the advice you have received or will receive about getting rid of your “mummy tummy.” Let’s start.
What is Diastasis Recti?
Diastasis recti is a larger than normal separation of the rectus abdominis, which is also known as your six pack. The aponeurosis insertions of the other abdominal muscles — the external oblique, internal oblique, and transverse abdominis —surround the rectus abdominis and merge to form the linea alba, a connective collagen sheath. You can feel the linea alba with your fingers, especially if you have a large gap.
Since the rectus abdominis is a paired muscle that runs vertically in two parts, a small gap between the two sides is normal. However, as the pregnant belly expands (or beer belly in men), the gap between the rectus grows. Actually, any outward force can widen the gap, which is why strenuous abdominal exercise can worsen or even create a small diastasis recti.
The linea alba isn’t a simple sheet that connects the rectus muscles. Rather, it is the hub where all the oblique (diagonal) and transverse (horizontal) fibers surrounding the abdominal muscles come together into one intermingled matrix. The aponeuroses go under and over the rectus abdominis, combining in the middle at the linea alba.
Does Pregnancy Cause Diastasis Recti?
Yes. DRA is ubiquitous among pregnant women (although persistent DRA is not). This makes sense. The belly has to go somewhere, so the connective tissue and muscles expand to make room for the baby. The linea alba doesn’t necessarily become inflamed or acutely injured by this process. It simply stretches; how much it stretches depends on the size of your belly and baby, but also on personal variations in connective tissue laxity. Additionally, the rectus sheath and the muscles stretch. The linea alba is just the part we can feel.
One school of thought claims pregnancy is not the actual cause of DRA. The argument goes that since men and non-pregnant women can separate their rectus, pregnancy is not the cause, but rather a mitigating factor. According to this theory, the primary cause is outward pressure created by the way a pregnant woman was and the postpartum woman continues to be aligned.
The alignment argument hinges on the premise that improper body mechanics keeps the linea alba artificially stretched, perpetuating any residual post-pregnancy DRA. If a woman “properly aligns,” then the fascia should bounce back. This argument also calls DRA a “symptom” of a larger problem, alluding to a lack of whole body alignment, a lack that theoretically alters pressure systems.
I’m skeptical of this theory. Although pregnancy is not the ONLY cause, it is the predominant one. This theory also depends on quite a few assumptions about correct alignment, alignment’s affect on pressure systems, and the ability of the fascia to fall into position. I’m not saying alignment (or posture) has NO relationship to DRA. Small changes in alignment probably help. Nonetheless, I doubt improper body mechanics is actually causing the diastasis or singlehandedly preventing it from closing, unless of course you walk around permanently holding your breath, ballooning your belly on purpose, or living your life in a perpetual backbend (so, please, don’t audition for the circus). Put another way–you’d probably notice if your internal pressure was wonky to the extreme, just as you probably noticed that baby pushing on your abdomen.
Therefore, I tend to believe alignment imperfections are micro-pressures compared to the macro-pressure of pregnancy. The linea alba’s recoil seems less related to your alignment than to how far it stretched in the first place. (Read more in The Alignment Cure and Does Neutral Posture Matter?)
If changing our posture won’t singlehandedly close DRA, does this mean we should ignore our alignment completely? No. We don’t have any evidence of alignment’s curative efficacy, but this doesn’t mean you won’t feel or look better with a little tweaking. Plus, better alignment is probably good for your pelvic floor. Personally, adopting a more neutral posture HAS helped. But, I consider it one possible piece of a complicated and obscure puzzle.
How Do You Know If You Have Diastasis Recti?
This is both an easy and a complicated question. Easy because you can self-test, complicated because the definition isn’t standardized. Let’s start with the easy way.
Lie on your back with knees bent. Make sure the lower back is not pressed into the ground, but not lifted too far up either. You should be able to snugly slide a hand between the floor and your lower back. If your rib cage points upward, the arch is too large. If this happens, place your hands on the bottom of your rib cage and push it down without flattening the back completely. Place your fingers together and perpendicular to your belly button.
Lift your head slightly until you can feel the two sides of your rectus abdominis. Stop as soon as you feel them. Do all four fingers slide neatly between the two sides? This is a 4 finger-width gap. Do only 3 or 2 or 1 or less than 1 finger fit? Number of fingers = size of gap. Do you need more fingers to fill the gap? Add in the fingers from your other hand.
Try this again a couple inches below your breastbone and a couple inches above your pubic bone. The rectus abdominis naturally narrows toward your pelvis, so the gap should be smaller or non-existent the further down you go.
But wait. Change the tilt of your pelvis, either pushing it into the ground or increasing the arch. Re-measure. Your size probably changes. Lift your head a little more. The size also changes. Which size is the real size? Frankly, it doesn’t matter. Measuring the gap gives you a decent baseline, but it’s not a science.
Many sources, such as Core Concepts Physical Therapy, say “a small separation of the midline at the abdominals, approximately one to two fingers’ width, is common after most pregnancies, and is not a problem,” therefore implying anything over 2 finger-widths is diastasis recti. However, other sources say the gap shouldn’t be more than 1.5 finger-widths, and still others insist you shouldn’t worry about finger-widths at all. Few sources note how mercurial the measurements can be in the first place.
I tend to believe finger-width DOESN’T ALWAYS MATTER. But, if you can fit 4 or 5 or 7 fingers between your rectus, you’re probably noticing some serious side effects like possible back pain, instability, or abdominal weakness. Or, maybe you still look pregnant and this distresses you (it did me). Therefore, finger-width DOES MATTER sometimes.
What Does the Research Say?
Some studies have looked at the abdominal gap post-pregnancy (IRD or Inter-Recti Distance). For example, a research report in the Journal of Orthopaedic and Sports Physical Therapy examined the inter-recti distance of parous women 7 weeks postpartum and then again at 6 months postpartum. They were compared to nulliparous controls.
The researchers also tested abdominal muscle strength. Larger gaps hadn’t yet been correlated with decreased muscle strength in the literature, although it had been hypothesized. The researchers found that 6–8 weeks postpartum the IRD distance ranged from 1.3 to 2.29 cm and 6 months postpartum from 1.16 to 2.13 cm. I measured my fingers. This came to about 1 to 2/2.25 finger-widths. A friend once lovingly called my fingers “freakishly small,” so that finger-width measurement is generous.
Also, they found “Negative relationships… between mean IRD values and abdominal muscle function at both 7 weeks and 6 months.” In other words, the larger the gap, the weaker the abdominals.
Meanwhile, nulliparous women had an average gap of 0.99 cm (about 1 finger-width) at the widest point and had stronger abdominals than postpartum women. The authors’ conclusion: “This study provides objective data that women at 6 months postpartum had larger IRD values and lesser abdominal muscle function compared to a control group of matched women without previous pregnancy.”
My take away: The gap will naturally get smaller, but won’t automatically return to pre-pregnancy size, and it doesn’t change that much from 7 weeks to 6 months in non-exercising women. I wonder how large the gaps had been at 1 week or 2 weeks postpartum. The difference between those numbers and the 7 week numbers would have been interesting.
Another take-away: The women in this study didn’t have large gaps and most didn’t have diastasis recti at the 7 week mark. Therefore, diastasis recti insight is only extrapolation. Still, we might conclude the larger the DRA, the weaker the muscles. We might also conclude DRA is anything larger than a 2 or 2.25 finger-width measurement.
Another study looked at the average width of the gap in 150 nulliparous women and found a wide range, but concluded “the linea alba can be considered ‘normal’ up to a width of 15 mm at the xiphoid, up to 22 mm at the reference point 3 cm above the umbilicus and up to 16 mm at the reference point 2 cm below the umbilicus in nulliparous women.” This equals about 2 of my finger-widths right above the umbilicus.
That study only looked at women who hadn’t given birth, so I turned to a Systematic Review on diastasis recti for a final answer on what actually constitutes DRA. The Review defined diastasis recti as a gap wider than 2.7 cm (roughly 2.5 finger-widths). The Review also noted that “natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time recovery plateaus.” Ah, this explains the lack of change in the first study.
Keep in mind, the research has looked at the size of the gap in postpartum women compared to nulliparous controls, but has told us little about when the gap is a problem. To answer this question, we need to take a closer look at the linea alba and its role in maintaining abdominal strength and support. We also need to consider the relationship between the pelvic floor and the inner abdominals. After we do all this, we can discuss what to do about a large gap.
After getting my information from online diastasis recti programs, I had an image of the linea alba as either a simple band connecting the right and left sides of the rectus abdominis or as the laces of a corset that can be tightened from each end by the transverse abdominis muscle. If only. To understand the role of the linea alba, we first need to picture the abdominal muscles.
A General Overview
The deepest muscle is the Transverse Abdominis (a.k.a. Transversus Abdominis a.k.a. Transverse Abdominus a.k.a. TvA). It helps with forceful expiration and spinal stability. This is the muscle most DRA programs emphasize.
The Internal Oblique (IO) lies above the TvA and below the External Oblique. The IO helps flex, bend, rotate, and compress the abdomen.
The External Oblique is the broadest and outermost abdominal muscle. The EO compresses the abdomen and flexes and bends the trunk. And, the Rectus Abdominis flexes the spine and helps forceful exhalation.
Remember, skeletal muscles have a connective tissue sheath. The connective tissue of the TvA, IO, and EO surround the RA, merging and forming the linea alba.
Imagine the linea alba as criss-crossed “plywood,” rather than as a sheet or corset. This means the fibers of the linea alba are an oblique and transverse matrix. Put simply, the fibers go side to side and diagonally. Even the transverse abdominis – the supposed corset – has fibers that “are not strictly transverse.”
Also, the linea alba is not uniform. It is separated into two sections, one above and one below the belly button, with a meshwork of various directions above and primarily horizontal fibers below. The linea alba naturally narrows towards the pelvis, becoming a “small, condensed, tendinous tract.”
I’m not sure what to do with all this information other than mention that the linea alba isn’t a simple, clearly understood horizontal belt that the TvA tightens and shortens. The TvA is a crucial, deep muscle; but, it is not the linea alba’s synonym or exact corollary. The TvA, IO, and EO all create the linea alba.
When the Linea Alba Stretches
Although the linea alba, like plywood, is fairly resistant to horizontal pull, it can over-stretch under enough consistent pressure. And when this happens, we are left with lovely diastasis recti.
DRA is not the result of large-scale tearing (although micro-tearing probably happens as it stretches). Uncoordinated tearing of the linea alba that allows the “the development of fatty protrusions” through the fiber bundles is a form of hernia. Your susceptibility depends on your individual anatomy and risk factors. Obesity and multipolarity (having multiple kids) are some of these risk factors; that said, most women with diastasis recti WILL NOT get one. Even so, diastasis recti combined with unkind genetics may predispose you to a hernia. Unlike DRA, a hernia can cause gastrointestinal symptoms, severe pain, and strangulation of tissue, so if you suspect a hernia and not just DRA, get thyself to a doctor.
The Linea Alba’s Importance
The biologist Garry Gillis explains in The Journal of Experimental Biology, “as aponeurotic tissue is stretched transversely, its longitudinal stiffness is increased. Recall that aponeuroses act as liaisons between muscles and their tendons, and if their stiffness can be modulated, so too can their effectiveness at transmitting forces…” Gillis isn’t referring to the linea alba, but the general role of abdominal connective tissue is the same: It’s a liaison for the abdominal muscles, and its stiffness helps transmit forces.
Since the abdominal aponeuroses generate tension and provide stability, lax connective tissue would have a harder time generating this tension. Logically, a very large diastasis recti would inhibit force transmission to and from the muscles (muscles that themselves are stretched out and weak).
Unfortunately, simply closing the diastasis recti might not be the most logical solution to this tension problem. In fact, some physical therapists (like Diane Lee) talk about the necessity of a taut linea alba to generate tension through the abdominal muscles. Consequently, she and others warn against artificially closing the gap with splints or with excessive emphasis on the IO, EO, and RA because this may inhibit the ability of the connective tissue to transmit force.
This theory is compelling, but no studies have looked at the impact of splinting on the ability or inability of the abdominal connective tissue to do its job. Perhaps the size of the gap matters irrespective of the linea alba tension. Or, perhaps splinting doesn’t reduce tension. Or, perhaps working the IO, EO, and RA creates enough tension. We have theories, but we don’t know much for sure. (I talk more about splinting later).
HOWEVER, assuming this tension is crucial, your inability to create it might require surgical intervention. If all the exercises in the world aren’t helping you tense the connective tissue, and thereby allowing the tissue to transmit force, a surgeon can manually move the two sides of your RA together and shorten your connective tissue.
Check Your Tension
Do not consider this self-check as a replacement for a medical professional’s evaluation.
Lie on your back with knees bent as if measuring the size of your diastasis recti. This time, before lifting your head, perform a Kegel that extends into your lower abdomen, which should activate your TvA. Imagine you are lifting your pelvic floor to your hips. If this doesn’t work, try a cue from the blog post 5 Transverse Abdominis Cues.
When I do a self-check without pre-contracting my TvA, I can fit 1 or 1.5 fingers. When I contract the TvA, I can fit 2, sometimes even 3, fingers. Notably, the wider version of my gap is also shallower (The gap used to be around 4.5 finger-widths, so overall it has gotten smaller).
Which size is my true size? It doesn’t matter. What matters is my ability to tense the linea alba and feel a difference. In other words, my connective tissue and abdominal muscles can work together to stabilize my body.
What if you can’t feel a difference? Well, maybe you instinctually tense the TvA, so consciously activating it doesn’t provide anything “extra,” which is good; or maybe you don’t have the muscle connections yet, which isn’t good, but can be fixed by exercise and physical therapy; or maybe your anatomy is shot and you aren’t able to generate any tension through the linea alba, which is not so good. But don’t take my or your own word for it. Go get a referral to a physical therapist or ask your doctor.
Wait, Are You Saying We Want a Bigger Gap?
You might be wondering why making the gap larger via tensing is a good thing, especially because larger gaps have been correlated with less abdominal strength. Don’t we want to narrow the gap, bringing the rectus muscles closer together? Umm. Well. Hmmm. Probably. This is actually a source of dispute and a head scratcher.
The most obvious way to tense the linea alba is to tense the transverse abdominis muscle, which, as you saw from the self-check, usually widens your gap. However, exercising the TvA strengthens your inner abdominals, and stronger muscles can exert a stronger pull on the linea alba, possibly remodeling the connective tissue and shortening the gap in the long term (this is a theory, not a fact).
Or, maybe this pull doesn’t shorten the gap at all, but does provide more stability and control through more stable connective tissue. Or, maybe the other abdominal muscles are preventing the TvA from widening the gap, while simultaneously strengthening the muscles enough to reposition the rectus closer together. This is why some therapists say the gap could get BIGGER or get SMALLER as you rehab.
Hold Up. Tensing the TvA Widens the Gap? Really?
Yep. And, according to new research, crunches NARROW the gap in postpartum women. Let that sink in. The crunch, the maligned and ridiculed and banned crunch, decreases inter-recti distance, while the ballyhooed and praised TvA increases it. This isn’t news to anyone who has actually tested their gap during a crunch, but some programs still insist that TvA contractions flatten the belly by decreasing the gap. This makes no sense. The TvA pulls horizontally on the linea alba. It creates tension by increasing the gap. That’s the way it works, at least in the short term. 
However, don’t start crunching to your heart’s content and don’t stop tensing your TvA. It’s still complicated (read more about the crunch here).
Most research hasn’t looked at the depth of the gap, only the inter-recti distance, and it hasn’t looked at how very large gaps respond to crunches. Nonetheless, it has questioned some assumptions about what will and will not narrow the gap.
A narrowing gap could be the result of internal oblique, external oblique, and rectus abdominis activation (as in the crunch). Although some therapists consider this a “non-optimal” way to correct the gap because the linea alba doesn’t fully tense, I remain unconvinced an isolated TvA movement is always ideal or even feasible. I worry the tension hypothesis can fetishize one abdominal muscle (the TvA) at the expense of the others. In many situations, the TvA will pre-contract with the pelvic floor, but the other abdominal muscles are friends, not villains, in the diastasis recti story.
Furthermore, even though the linea alba is important, most tummy tucks don’t repair it. One plastic surgeon told me “most often, it is not directly operated on during tummy tucks, even when it’s stretched out, but rather, the anterior fascia over the muscles is used to repair the laxity.” This suggests the main benefit of surgery isn’t fixing the linea alba per se, but rather bringing the muscles and connective tissue back together so they can provide more stability. After surgery, they are no longer yelling across a floppy, saggy void. Clearly, the size of the gap AND fascial tension matters.
Not Only the Linea Alba Stretched
The intra-abdominal pressure that precipitated your DRA also left its handiwork on your entire midsection. Diastasis recti can cause a bulging belly, but so can weak and stretchy muscles. Pregnancy expanded the rectus abdominis, internal oblique, and external oblique; therefore, they need some love too. The linea alba may be the part we can palpate and stick our fingers in, but it’s not a monomaniacal key for unlocking a flat(ter) belly.
Should We Worry if the Gap Grows?
I think so. A large gap shouldn’t be ever expanding. Sure, we shouldn’t obsess about the size. We shouldn’t assume function can only correspond to a specific finger-width. But neither should we discount the benefits of narrowing our diastasis recti.
Core weakness can have multiple antecedents, not least of which are over-stretched connective tissue AND extra space between the rectus muscles, which is why narrowing the gap still seems worthwhile. Yet, what to do with the news that a tense linea alba may be a wider linea alba? This riddle is super frustrating. It is also at the heart of diastasis recti debates.
What About That Paradox?
Okay. I’ve avoided it long enough. Let’s tackle that paradox and enter into the DRA debates.
How do we tense and compress the linea alba? This is like simultaneously pulling and pushing on a rubber band.
Indeed, this seeming paradox is the source of difference among many of the online programs and physical therapy techniques. It is why some experts insist on splinting and others warn against it.
I admit, the compression versus tension conundrum hurts by brain, so instead of giving a clear cut answer, I’ll lay out the theories and then tell you what makes sense to me. I’ll focus on general approaches, but if you want me to name names, read the following post about my own experience with the various methods and programs: How I Narrowed My Diastasis Recti.
Can you Strengthen and/or Shorten the Linea Alba?
This is surprisingly hard to answer. In the first 8-12 weeks post-childbirth, absolutely. The tissue experiences recoil after the stretch is taken away. And after that window? Anecdotally, yes. Also, we have some evidence of natural shrinkage. For example, a 2015 study looked at the prevalence of DRA from late pregnancy to 6 months postpartum. It decreased from 100% at 35 weeks gestation to 39% at 6 months postpartum. Not all of this decrease happened in the first few months, but most did. Notably, the gap didn’t return to pre-pregnancy sizes.
However, a couple years after the birth of my second child and newly pregnant with my third child, I spoke with a surgeon about my gap and he said “no exercise in the world would close it” because the linea alba is not compressible. This means overstretched connective tissue can’t reconfigure itself, just as excess skin doesn’t go away. Therefore, according to this surgeon, the shortening that many moms have experienced after embarking on an exercise program is not the result of actual “healing,” but most likely the result of overall abdominal strengthening, creating the illusion of a smaller gap.
Huh. This doctor was probably too pessimistic. Plausibly, the abdominal connective tissue may shorten. By how much? Well, that is up in the air.
Still, he was right that we lack strong evidence suggesting connective tissue can easily or quickly “remake” itself, which is why we should question programs aimed at getting us to take collagen supplements (just eat adequate protein) or aimed at radically altering the integrity of the tissue in a matter of weeks. The programs may help us narrow the gap, but short term narrowing probably results from muscle change rather than tissue change, which isn’t bad per se, just not as advertised.
Some of you might be saying, “I thought fascia and connective tissue could remodel and strengthen itself much like muscle.” (Don’t worry if you weren’t asking yourself this…) Anyway, it can. However, is this happening to the linea alba during normal exercise? Maybe. Maybe not.
A 2007 article with the sexy name “Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude” gets a lot of play as evidence that “tendons are able to remodel their mechanical and morphological properties in response to mechanical loading.” The study found that after 14 weeks of high strain exercise, the Achilles tendon became stiffer and thicker. Cool.
Ah, but one caveat: “Tendon–aponeurosis stiffness increased significantly (P<0.05) only in the high-strain-exercised leg.” The subjects’ opposite legs, which had also been exercised but not as vigorously, did not show these changes. This is good news for the Achilles tendon, but irrelevant news for the linea alba.
Another oft cited study called “Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps muscle after exercise” showed that “there is a rapid increase in collagen synthesis after strenuous exercise in human tendon and muscle.” More good news for connective tissue.
However, I must crash the connective tissue party and offer another caveat: The collagen synthesis associated with short term high intensity leg exercises performed by young, healthy men is not exactly a roadmap for altering the collagen in the abdominal fascia of postpartum women. In other words, we have to quantum leap from a small study on tendon hypertrophy to a presumption we can significantly remake the abdomen’s stretched out connective tissue.
Frankly, the collagen studies are cool and promising, but we can’t directly translate them to the linea alba. Too often we take findings like this and catapult promising results into unwarranted hype. The body is more complicated than that.
Therefore, before jumping to conclusions about DRA, we should ask ourselves:
- Does stretched tissue need more or less load to strengthen than “normal” tissue does?
- Is it even possible to create extremely high strain on the linea alba?
- Do isometric contractions provide enough tension to do anything?
- How would you overload the abdomen to cause a difference?
- And, even if you could, would you simply cause other problems, for example, too much pressure on the pelvic floor?
Personally, as my muscles got stronger, my connective tissue also felt stronger and shorter. Since exercise simultaneously loaded my muscles and tissues, this hypothesis is plausible.
But, to what degree was the tissue being remade and to what degree was I simply noticing the muscles tense the tissue? Or, maybe I was noticing the muscles create a brace that took some of the outward pressure off the tissue? I don’t know the exact mechanism for bridging the gap, and I highly doubt others do.
My point: let’s not get ahead of the evidence when trying to explain how or if the linea alba can strengthen or shorten.
Immediately postpartum, the tissue clearly can “bounce back,” but it shortens via removal of the baby (the intra-abdominal pressure). After that, shortening mechanisms become more conjecture than fact. This doesn’t mean it can’t happen (indeed the limited evidence suggests it can, as does my personal experience), but it does mean we need to temper over-confidence about our knowledge of the mechanism.
If High Strain Loading Isn’t the Automatic Key, What About Altering the Source Material?
Can we increase collagen production to “heal” the linea alba? Collagen makes up a large part of connective tissue. It is also dynamic. Consequently, many sources emphasize collagen health as the framework for DRA “healing.” An obvious example of collagen’s dynamism is the effect of dehydration or cigarette smoking on the skin. Clearly, collagen can degrade. The optimistic corollary is that it can also replenish. However, dynamic doesn’t mean easily shortened or repaired. We can’t just drink a glass of water or sip some bone broth and watch the linea alba plump up.
The skin makes a useful linea alba analogy because of its high collagen component (Although, frankly, the body is like a vat of collagen. It is everywhere). Cut skin will heal. Stretched skin will bounce back. This is why most bodies don’t cart around floppy skin after moderate weight loss, including postpartum. Unfortunately, skin’s spring is not unlimited. Stretch it too far and its recoil is lost, which is why some women DO cart around floppy skin after extreme weight loss, including postpartum. (My kangaroo pouch is personal evidence that collagen won’t simply shorten because we drink our water and eat protein).
The analogy isn’t an exact parallel, but the difference between cut skin and stretched skin is applicable to the linea alba. Consequently, any program promising to “heal” or “repair” or “shorten” your linea alba via diet is out of its explanatory depth and should be approached skeptically.
Of course, I’m not saying diet doesn’t matter at all. If you are deficient in some essential vitamins and minerals, or if you don’t eat enough protein, your muscles and tissue will have a harder time responding to exercise. However, recommendations for very specific foods or supplements as the key to linea alba remodeling make little anatomical sense. Conversely, a varied diet with fruits, vegetables, and protein is always good for you, diastasis or not.
Moving on: Even if we don’t exactly know HOW the gap narrows, we at least should know IF it narrows. Again, based on anecdote, yes it can.
Leaving Anecdote Aside, What Do the Studies Say?
Nevertheless, the Systematic Review is enlightening. Their findings:
Eight studies totaling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomised controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.
The papers reviewed were of poor quality as there is very little high-quality literature on the subject.
Leading to their unenthusiastic conclusion:
Due to the low number and quality of included articles, there is insufficient evidence to recommend that exercise may help to prevent or reduce DRAM.
In other words, a systematic review is only as good as what goes in. If what goes in is poor, what comes out is inconclusive. This is why their recommendations were vague despite some positive evidence. Why were the studies poor? Because most weren’t systematized, randomized, or controlled.
First, the systemization problem: Some studies used callipers to measure DRA. Others used tape measures, and others just used fingers. And the studies didn’t even agree on what constituted DRA. Some said it was a gap greater than 2 cm, others that it was a gap greater than 2.5 cm, and others that it was a gap greater than 3 cm. Therefore, comparing the studies is like comparing apples and oranges. They may both be fruit, but they ain’t the same.
Next, the study design problems: Many of the included studies didn’t properly randomize the sample groups, which means positive results could have been sampling noise resulting from differences among the baseline groups.
Hallmarks of good evidence are large group sizes and complete randomization into these groups. Otherwise, the results can be skewed, intentionally or not. Too many of the included studies lacked these hallmarks, leading to the Systematic Review’s ambivalent and unenthusiastic endorsement of exercise based interventions.
The gold standard of sound evidence is a randomized controlled trial (RCT). In an RCT, the sample groups are random and an intervention group is compared to a placebo group (receiving no intervention). Furthermore, to prevent bias, the trial assessors are blinded to the group they are evaluating, although this isn’t always possible.
Out of the 8 trials in the Review, only 1 was a randomized controlled trial. Frustratingly, this RCT isn’t that useful because it only looked at the effect of 2 sessions of abdominal and pelvic floor exercises 6 and 18 HOURS after delivery. Unless you are reading this essay 6 hours after giving birth (I suspect you are not) that window is way too small to say anything about DRA closure in the weeks and months afterwards! The Systematic Review put this more diplomatically, saying the results “may not be clinically relevant.” You think?
The Systematic Review also included the 2005 study often touted as evidence for a popular online program (one that involves splinting and repetitive TvA pulses). The study received a 14/28 on the quality scale, which was deemed “poor.” Furthermore, this study only looked at pregnant women, not postpartum women, something the advertisements for the program fail to mention. The study was small, only 8 in the exercising group and 10 in the control, and did not require participants to wear splints or to repeatedly sit still and pulse one muscle. As a result, we should be wary when an online program claims to have conclusive evidence. As far as DRA is concerned, high quality randomized controlled trials don’t exist. Conclusive evidence is still a mirage.
The News From the Systematic Review Isn’t All Bad
Pregnant women who exercised had smaller gaps than non-exercising controls, probably because strong muscles were able to counter some of the abdominal stretch. The reviewers had a similar hypothesis:
A possible explanation for how exercise during the antenatal period may reduce the risk of developing DRAM is that exercise helps to maintain tone, strength and control of the abdominal muscles, consequently reducing stress on the linea alba. Additionally, women who exercise during pregnancy generally also exercise prior to pregnancy and, therefore, may be fitter and have better conditioned abdominal muscles compared with women who do not exercise during pregnancy.
However, the authors’ hypothesis for why exercise could potentially narrow postpartum DRA is less convincing. They concluded that
activation and exercise of the transversus abdominis muscle draws the bellies of the rectus abdominis muscle together, improves the integrity of the linea alba and increases fascial tension, allowing efficient load transference and torque production. Potentially, transversus abdominis muscle activation could be protective of the linea alba and may help to prevent or reduce DRAM and speed up recovery, allowing women to return to their usual physical and social activities more quickly.
This argument falls flat for several reasons. First, the authors didn’t explain the mechanism for closing DRA other than through “protecting” the linea alba by contracting the TvA. What does protecting mean? That it takes the pressure off it? What does “improves the integrity” mean? Words matter and these words are vague. Is this protection to the integrity possible after 8 weeks postpartum? On an already stretched linea alba? Also, the authors hypothesized that contracting the TvA brings the rectus abdominis closer together, but multiple recent studies, not to mention personal experience, prove the OPPOSITE.
However, exercise seems to be doing something. Perhaps in the first postpartum weeks, as the linea alba naturally shrinks back to size, this tensing could help narrow the gap by creating a tighter muscular brace. I don’t know. I’m spit-balling. Also, proper activation of the TvA and other abdominal muscles could prevent excess pooch. For example, if a mom habitually pushes out her abdominal muscles when working beyond her capacity, pre-contracting the TvA could prevent this and could then, in a way, bring the rectus together. Or, maybe abdominal work simply strengthens and condenses the stretched out muscles. So many “maybes.”
Overall, the Systematic Review left me confused about the evidence for DRA narrowing. The gap probably can narrow with exercise, but the explanatory mechanisms are still cloudy.
Let us assume the gap can narrow. Mine did, so I’m biased. And, a few studies suggest it might shorten for some women. If we accept that the gap can narrow, even if we don’t know the precise mechanisms for this narrowing, what is the best way to do it?
Let’s look at some of the common suggestions and their rationales. I don’t separate this section by each individual program. Instead, I look at methods, many of which overlap among programs and physical therapy treatments.
1. Splint and Squeeze Method
A popular method is what I call “the splint and squeeze.” A splint approximates the two sides of the rectus. Then, belly is pulled to spine to strengthen the transverse abdominis muscle, which is supposed to shorten the linea alba. The main premise is that the connective tissue needs to “heal” and this healing is accomplished via TvA strengthening.
But wait, doesn’t splinting make the linea alba loosey goosey, thereby preventing the proper amount of pull and tension? If we take out the pull, will we inhibit connective tissue strengthening, or, even worse, prevent force transmission from the linea alba through the muscles? Maybe. Therefore, some therapists assume splinting discourages strengthening, although, to be fair, that isn’t proven any more than splinting’s benefits are, e.g. both theories are unproven.
Still, this critique has teeth. A good explanation of tensile strength comes from a Carnegie Mellon Open Learning Initiative Course:
Collagen fibers have significant tensile strength, which means that they can withstand a lot of tension (pulling) without damage. However, collagen fibers have very little compressive strength—that is, under compression (squeezing), they bend easily. You can think of a collagen fiber as a rubber band or string. If you pull on a rubber band, it stretches easily, and then returns to its original shape when you stop pulling. However, if you push on the ends of the rubber band, it folds up easily—it has minimal strength.
Vis-a-vis the linea alba and splinting, compressing the two sides of the rectus possibly folds up the rubber band that is your connective tissue.
However, to critique the critique, do we know how much tension the linea alba needs or if the tension is actually remodeling anything? Plus, maybe splints are making the linea alba more, rather than less, effective. I just don’t know.
To complicate matters, the collagen fibers of the overly stretched linea alba have not withstood a lot of tension and have not returned to their original shape. They have been overloaded and thus DAMAGED. However, does this mean diastasis recti is an INJURY? The vocabulary matters. How can we figure out what will fix the damage if we don’t understand the type? How do we know if splinting is a good idea?
Ergo, whether splinting is good or bad depends on how you rank the following:
- approximating the muscles closer together to provide a stronger contraction versus
- creating the strongest pull on the connective tissue
The ranking isn’t clear to me, but I suspect both sides overstate their cases.
To Splint or Not to Splint
Splinting may hinder because it folds up your linea alba rubber band, but paradoxically it may help because it brings the rectus abdominis closer and allows for a stronger and more stable contraction.
So, is splinting good or bad?
The answer depends on your goals and expectations. Splinting provides temporary stability, but can’t force the gap permanently shut and may be counterproductive in the long run.
Also, splinting isn’t “healing” your connective tissue. Healing is based on the premise that the linea alba is INJURED and therefore needs compression. If DRA were a wound, the following explanation from an article on plastic surgery would apply:
The re-establishment of abdominal wall strength depends upon the synthesis of new connective tissue…. Factors limiting the availability of … critical substances and conditions will delay or impair the development of wound strength and increase the likelihood of wound disruption…. Maximum strength development does not occur for several months and depends upon the interconnection of the collagen subunits. Approximately 80% of original strength is reached in about 6 weeks and can be significantly delayed if the normal factors for wound repair are not present.
This version of wound repair has greatly influenced the splinting advice for DRA. In this vein, one diastasis recti source even authoritatively announced that linea alba collagen is restored after 200 days. But, 200 days from when? From giving birth? From starting exercises? From wearing a splint?
This advice assumes DRA is an injury analogous to a wound, or even to a sprain or strain. Only problem: it’s not. If it were, compressing the abdomen to allow proper healing as the collagen synthesized might make sense. But if it’s not a wound, what is it? Is it an acute injury or is it damage? I suspect the answer is damage. Therefore, the mechanics for recovery are not the same as wound repair or tendon compression.
A Recap: The arguments for and against splinting come down to a debate over compression versus loading.
I’m not ready to say splinting has no place or cannot help DRA. For example, I’m not sure if splinting inhibits the pull on connective tissue as much as some assume. If a splint brings the muscles closer together, which allows for a stronger contraction, it might actually help the tension conundrum.
Also, splints can be wonderful in providing support to encourage movement, not by altering the connective tissue, but by supplementing the tissue. For example, I wore a splint throughout my second and third pregnancies to combat back pain and to keep me active. My muscles didn’t weaken, as some feared. The muscles actually got stronger because I wasn’t forced into a convalescence. The splint propped up my growing belly and became a much loved and needed daily friend.
Likewise, splints are especially helpful post-childbirth. Perhaps, in the early weeks when the muscles and tissues are “bouncing back” and engaging in some recoil, the splinting will encourage this, not by “healing” anything, but by reminding the tissue where to go (my non-scientific term). It can also take some pressure off the tissue as you strengthen your abdominal muscles, which feels like an overall good (as in literally — it felt good after childbirth).
Admittedly, I have NO EVIDENCE for this, but it seems plausible. Regardless, a post-pregnancy splint provides stability and can encourage movement, especially if you’ve had a c-section and/or have a large gap between your rectus muscles (DRA rates are NOT more common among c-sections, but a c-section does present its own wound repair and compression considerations).
What if you are many months or years post-pregnancy? Outside the immediate postpartum window, a splint may help large gaps if it can encourage a proper contraction of the muscles. I doubt it can single-handedly narrow diastasis recti (removing the splint usually removes any temporary closing), but if it gets you to engage your muscles, it’s doing a good job. Conversely, if it makes you scared to move, don’t use it. And remember, a splint is a temporary brace, not a DRA solution.
Overall, a splint might inhibit loading, but might encourage movement and tissue recoil. 1 point against, 1 point for.
Ah, except, the splint has one last problem, and this problem is practical, not theoretical.
A splint can have unintended consequences. I’ve tried quite a few, and every single one has shifted into a belt throughout the day, no matter how many times I adjusted it.
Post pregnancy I got around this dilemma by wearing my favorite splint underneath a postpartum binder with a crotch strap (check my Resources page). I wore the splint/binder combo after my third child because I wanted some stability, which it provided, and because I wondered if I could get my tissue to bounce back, which was a lost cause; my first two pregnancies had already done their work. This combo solved the shifty splint issue, but was not a long-term solution. No splint is.
Another crucial splint problem relates to the first. A tight, movable splint can create a belt around your midsection that pushes your viscera up and down. The abdomen is a closed system. The best analogy is a balloon. You can change the shape, but can’t remove the contents, unless of course the balloon pops. Your body’s version of popping is prolapse (I’m not saying splinting causes prolapse, but it doesn’t help).
Some physical therapists discourage any and all splinting because they worry about this downward assault. But, other therapists prescribe splints because some abdominal pushback isn’t a bad idea for overly stretched muscles and fascia.
Moderate binding probably doesn’t harm your pelvic floor, prolapse or not. However, a too tight splint that’s always cinching your midsection like a belt IS a problem. Some of the splinting proponents want you to wear the splint super tight. For example, one particular splint seller claims an added benefit of splinting is reduced stomach capacity and consequent weight loss (because you are eating less). That is insane. If your stomach is so compressed you don’t feel like eating, the splint is too tight! Where do you think your squished stomach goes? Look downward for the answer. Your pelvic floor begs you to stop.
Overall, splinting can be helpful. It can help stability. It can help you reconnect to your muscles. But it might not help your connective tissue, and it’s not healing anything (You can also read Should You Splint Diastasis Recti?)
One last thought: if you splint, I do not recommend sitting still while pulling belly to spine over and over and over. A splint should encourage movement, not make you afraid to load your muscles.
2. The Transverse Abdominis Corset Theory
The transverse abdominis is Queen, at least according to most diastasis recti specialists. Some programs even claim the TvA is practically magic and acts like a corset to pull the gap back together. That’s not true. It’s an important muscle, perhaps even the Queen, but it’s not a Sorcerer.
Let’s put the transverse abdominis into context. Its primacy is not universally accepted in all circles, mostly in those looking at the spine and low back pain. If you want to know more about the TvA’s ascension to the throne and why it has provoked debate, read this post by Greg Lehman. I won’t go into the whole controversy. I’ve read Stuart McGill’s book and looked into Paul Hodges’ work (who collaborates a bit with Diane Lee), but the intricacies of the digressions are beyond the scope of this primer (and my education). Also, most of the debates address low back pain rather than DRA.
In the postpartum women’s health world, somehow the TvA and the linea alba turned into synonyms, as if contracting one meant healing the other. But why? Hodges suggests the TvA helps with stability by increasing intra-abdominal pressure and tensing the fascia. However, why would contracting the TvA close a diastasis recti? The leap seems large, especially because drawing “belly to spine” INCREASES rather than DECREASES inter-recti distance in postpartum women. Therefore, the entire notion of closing the gap with repetitive TvA pulses is built upon faulty assumptions (For the record, Hodges never said to repetitively pulse the TvA).
For our purposes, we should know that Hodges’ early work was hugely misrepresented by practitioners and his limited findings were erroneously simplified by those who latched onto the image of the TvA as the most important abdominal muscle. More recently, Hodges has said,
While changes in transversus abdominis (and other muscles such as multifidus) can be a useful marker of dysfunction in the system…to limit treatment to this muscle is unlikely to be beneficial. The days of contracting transversus abdominis as the primary exercise and then sending the patient away are over. Instead, training of transversus abdominis should be part of the intervention, when appropriate for the patient and their control system changes.
In other words, the TvA is just one muscle trying to get along with the rest. Yes, it is an important muscle; as the innermost abdominal muscle, the TvA is the first line defense against hernias and essential for creating force closure, but it is not floating around by itself.
The TvA is not a magic corset, but is it “optimal”?
We can all agree that repetitively contracting the TvA over and over is a bad idea, but should it pre-contract before other movements? Physical therapists like Diane Lee believe an “optimal” curl-up pre-activates the TvA. This seems to be based on the work of Hodges and the assumption that over-activating the external abdominals, especially the internal oblique and external oblique, does not provide optimal spinal control, perhaps over-stabilizing and over-bracing the spine.
Lee’s intriguing research has looked at muscle activation during a curl-up, i.e. if it is happening and where. Lee noticed that when women with diastasis recti activated the TvA before a crunch, they had more tension on the linea alba than when they did not pre-activate. Additionally, her ultrasound imaging showed that contracting the IO in a curl up, as opposed to the TvA, can shrink the gap, yet create more slack in the linea alba. Presumably this is bad because the muscles generate less tension through the abdominal fascia. Many fitness and physical therapy professionals have interpreted these findings as evidence that an optimal pattern of muscle recruitment starts with the TvA.
I’m sorta convinced. However, function is as function does, right? We don’t live in bodies that only activate the TvA and exclude the other abdominal muscles. A curl-up task provides little information about upright stability exercises, eventual DRA size, or long term tissue quality. I doubt we should worry if the gap shrinks because of heterogeneous exercise that varies muscle activation patterns, whether the IO or TvA is the prime mover or not.
Additionally, a 2015 study showed a decrease in inter-recti distance in postpartum women when they did an abdominal crunch without any particular cueing of the TvA, but no decrease when the TvA was pre-contracted (the inter-recti distance stayed the same). Conversely, an isolated TvA contraction caused an increase of inter-recti distance. The authors of that study even said
Given the results of the present study, which show an increase in IRD below the umbilicus during the drawing-in exercise, the recommendation of this exercise for women who have undergone a caesarean section is questioned. At this measurement point, the muscle bellies and abdominal fascia are moved apart, which may reduce the ability of the muscles to generate enough tensile force.
Whoa. They actually warned AGAINST TvA activation for women who’ve undergone c-sections. That’s quite a mind bender considering all the adoration that’s been heaped upon the TvA by every postpartum specialist like ever.
Personally, I had one c-section, and I did loads of TvA contractions afterwards as a way to stabilize my midsection while doing things like heel slides, leg lifts, etc… Notably, I did not do repetitive isometric TvA contractions. I didn’t notice any long term widening of my gap, so it might be a bridge too far to actually warn women from TvA contractions (although, again, too many isometric ones aren’t doing any good). Also, studies like this have looked at DRA width, not depth, so I’m not willing to give up all TvA pre- contractions, especially because the TvA is the pelvic floor’s BFF for a lot of women.
Nonetheless, the TvA isn’t magic (and crunches aren’t evil)! The evidence is not as simple as “the TvA is always optimal.”
What’s so bad about the Internal Oblique, External Oblique, and Rectus Abdominis?
Usually the IO, EO, and RA are maligned because of fears about excessive intra-abdominal pressure (IAP). IAP provides stability. Contracting the TvA creates IAP, which the pelvic floor reacts against by co-contracting (as long as everything works properly). This is necessary. However, excessive IAP overloads the pelvic floor and sometimes even the abdominal muscles themselves. Does IO, EO, and RA activation create too much IAP at the expense of localized stability? Interesting question.
Many women with pelvic floor problems are discouraged from working the outermost muscles under the assumption the pelvic floor can’t counteract the IAP they produce. Similarly, most women’s health professionals frown upon any exercise that doesn’t pre-activate the TvA and the pelvic floor.
Most therapists prefer a TvA pre-contraction because some studies have shown TvA activation during a pelvic floor muscle contraction. However, other studies have shown that many women activate the TvA WITHOUT simultaneously contracting the pelvic floor, another reason NOT TO do repetitive TvA contractions if you don’t know what is going on down under.
Although the pelvic floor and inner abdominals absolutely need to counteract IAP, I’m wary of making hard and fast activation rules against the other muscles. Close attention to your own body is warranted. If your gap narrows and you aren’t peeing yourself, I wouldn’t freak out about your possible “non-optimal” activation strategies. If you were overloading the muscles and busting IAP off the charts, I just don’t see how the gap would be getting smaller in the first place. Therefore, smaller gap is still a good thing, assuming it has been achieved without compromising your pelvic floor.
Even so, DRA makes and results from weak and uncoordinated muscles. I imagine contracting the pelvic floor and then feeling this contraction move into the TvA is good at creating a stabilizing “force closure.” But, extrapolating that the TvA needs to be pre-contracted before every movement or that the other muscles are non-optimal or that the best way to close DRA is by always focusing on the TvA depends on a lot of assumptions the evidence doesn’t support. If I had to suggest a quick shorthand, it would focus less on TvA isolation and more on the pelvic floor, as in make sure your pelvic floor can absorb IAP created by ANY abdominal muscle.
Ultimately, the body is not a tidy crossword puzzle with transverse abdominis as the answer to “What is the most important abdominal muscle?”
Furthermore, we roam into tenuous territory when solutions for “fixing” TvA activation problems are suppositions that such and such muscle needs to be released or unwound. Muscle and rib releases, dry needling, precision stretching, and other hallmarks of manual therapy aren’t always supported by robust evidence. It is beyond my scope to comment on the efficacy of these approaches, but I’d be skeptical of any practitioner who claims she can fix your DRA or provide complete function with a couple stretches, a TvA contraction, and an optimistic smile.
3. Corrective Exercise (a.k.a. A Holistic or Whole Body Approach)
A holistic approach to diastasis recti is the newest online offering, usually invoking phrases such as “whole body solutions” or “corrective exercise.” Admittedly, DRA is a complicated dilemma. Even so, what exactly is a “whole body” approach to diastasis recti? The terms “whole body” and “holistic” are akin to “natural”; in other words, they are vague and mostly unhelpful.
For example, does “whole body” mean moving the entire body? That would make sense, but isn’t “exercise” another word for this? Or, is “whole body” code for “alignment”? Or, does it mean manual therapy? Or, does it mean breathing deeply and chilling out? Or, maybe it means eating your veggies and a ton of bone broth? Or, drinking gallons of water? Or, does it mean… You get my point.
In general, the terms are unobtrusive. The most generous definition of a “whole body approach” is to stop obsessing about one muscle and one type of muscle activation. If this means focusing on many forms of mindful movement, I’m totally on board.
But, when “whole body” is code for dubious DRA solutions, I’m jumping ship. Red flags should pop up when any practitioner insists upon fascial release, or perfect alignment, or acupuncture, or healing, or any other theory that pretends we are machines that can be tightened or loosened at will. The lion’s share of DRA solutions are guess work, like most emerging fields. This doesn’t mean certain exercises and techniques won’t help, but neither does it mean the answer is hidden behind a “holistic” or “whole body” linguistic veneer. If someone uses the term “whole body,” ask for a more precise definition. And, then ask for evidence.
We know some women with diastasis recti have trouble tensing the linea alba and/or lifting the pelvic floor. We know all the abdominal muscles are stretched, weak, and likely uncoordinated. We know the connective tissue is thin. We know loading can help other types of connective tissue, but may or may not affect the linea alba. We know bringing the muscles together helps with strength. We know the cause of the gap was excessive outward pressure via growing a baby.
So… what do we do now?
- Do we re-teach activation patterns, i.e. teach women how to coordinate a contraction of the pelvic floor with the inner abdominals? That seems like a really good idea. Stability requires the right amount of intra-abdominal pressure, enough to prevent wobble, but not so much that the pelvic floor can’t contract against it.
- Do we focus on asymmetries? I don’t know. A lot of physical therapists do, and I went to a functional fitness trainer who obsessed over that stuff, but does it really matter? Bodies can deal with asymmetry. Most of us aren’t perfectly symmetrical anyway. At what point are we pathologizing a norm and how much would “correcting” the asymmetry affect DRA?
- Do we dry needle to release tension in tight areas? Releasing tension is good, but this feels like fiddling around in the wrong corner.
- Do we adopt proper alignment to regulate pressure? Sure. However, I’d still focus on strength and coordination. Postural extremes probably overstretch parts of the abdomen, but simply finding the perfect way to stand isn’t that feasible and isn’t going to zip DRA up. Standing in a more neutral posture might feel better and look better than your normal posture; it might even stop some stretch (which is obviously important), but posture isn’t that easy to change and it isn’t a stand-alone cure. Alignment is contextual, and the context should be moving and loading your muscles. Read more in Does Neutral Matter? and The Alignment Cure.
- Do we throw our hands up in the air and schedule our tummy tucks? Not always. You can narrow the gap without surgery, but this doesn’t mean you will, nor that you need to (depending on the size of your gap). Too often we conflate can with will. Some women can narrow the gap and regain strength for various, mostly unknown, reasons. Some women can regain strength without budging the gap. And some women can’t do either. A doctor and physical therapist will help you determine if your DRA is functional, on the road to becoming functional without surgery, or only fixable via some cutting and moving.
- Do we exercise appropriately? YES! I’m skeptical of authoritative pronouncements of how to close a diastasis recti, but I’m not skeptical that exercise might narrow it. I’ve explained why some of the theories and rationales don’t make sense or aren’t supported by evidence, but the limited evidence we do have suggests exercise is your best first step.
Therefore, move…within reason.
1. Start with simple abdominal exercises and work up to full body conditioning.
Are crunches and planks simple abdominal exercises? It depends. These aren’t off the table, but those of you with a large diastasis recti are unlikely to perform them safely or effectively on your first go. Whether a crunch or plank is appropriate depends on where all the intra-abdominal pressure is going and if your pelvic floor and abdomen can counteract it. Of course, that is true with any exercise.
You can work up to more strenuous exercises, like variations of the plank, even if you never close your DRA, but you do need control over the movement and your muscles. In other words, don’t jump into a postnatal stroller class and plank with everyone else. Don’t imagine yourself a Spartan Crossfit warrior either.
You can start with my 8 exercise routine. After mastering those exercises, add in varied resistance training. Don’t be afraid to load your muscles. I only saw measurable improvement in my DRA after I added more load. However, I didn’t add more load until I knew how to do the simple exercises first. Therefore, start gently, and then move on to progressively more challenging full body exercises.
I like to say “don’t be stupid, but don’t be afraid.” If your abdomen (or pelvic floor) splays out, pooches out, or generally feels out of control, stop the exercise! On the other hand, if gentle abdominal contractions, balance exercises, and diaphragmatic breathing aren’t doing enough, then do more!
2. Do not regularly stand and sit in ways that overstretch your abdominal muscles.
I may be skeptical of the myriad alignment claims, but reasonable attention to your posture might help. Again, attention is not the same as obsession. Read What is Neutral for advice on how to do this.
3. Do not perform activities that re-introduce excessive abdominal pressure, albeit on a lesser scale than during pregnancy.
For example, if you can’t get up from a back lying position without holding your breath or doming your abdomen, roll to the side and push yourself up. If you stand or move in ways that exacerbate outward pressure, pay attention to your posture. If you can’t hold any kind of plank or push-up without losing control of your abdomen and pelvic floor, regress the exercise. Know thy limits. Push the limits, BUT STILL KNOW THEM.
4. Learn how to perform an ascending contraction coordinated with your breath.
Directions: During strength training or daily heavy lifting, consciously ascend the contraction, which means start from the pelvic floor.
a. On an out-breath, gently contract the pelvic floor (don’t overdo it).
b. Feel the pelvic contraction move into your abdomen (the TvA and the rest of the abdominals).
c. Then, move the parts of the body that need moving.
Exercise and movement will create IAP. This is necessary. The goal of an ascending contraction is to counteract this IAP. Eventually, this type of contraction will become second nature.
If it helps, picture an arrow moving from your pelvic floor into your abdomen into your other muscles (this is more visual than literal since many muscles will contract at the same time). Your pelvic floor should slightly pre-contract in expectation of increased intra-abdominal pressure.
Exercise is your best chance at remedying diastasis recti without surgery. Get moving without fear you will break yourself.
- Buy some resistance bands or free weights.
- Consider a personal trainer or Pilates instructor.
- Use a TRX.
- Take a barre class, etc.
Non-stop aerobics or hours on the elliptical won’t cut it; make sure you incorporate resistance training.
Remember, stay away from some of the “core work” in group exercise classes or any other exercise that is too difficult for your weak abdominal muscles.
Do modifications, such as the 8 at the end of this essay.
If anyone asks why you are modifying, consider it an opportunity to educate another woman about diastasis recti.
- Do gentle abdominal exercises every day.
- Do varied resistance training.
- Ignore the advice of the over-confident.
- Don’t be afraid to move, but don’t stick your head in the sand either. If your movements are making the gap bigger, stop.
I can’t make promises.
- I can’t give you a clear handout of Dos and Don’ts.
- I can’t promise you that simple changes to your posture or breathing will close the gap.
- I can’t sell you a splint that will “heal” your connective tissue.
- I can’t give you the perfect exercises.
- I can’t pretend like the information on DRA is conclusive.
But, I can tell you…
- I can tell you the abdominals might strengthen.
- I can tell you the gap might narrow.
- I can tell you a gap doesn’t prohibit a flat belly. As you strengthen your abdominal muscles and reduce fat via diet, you should notice improvement, even if the gap doesn’t close all the way.
- I can tell you needing or deciding upon surgery is not failure.
- I can remind you that you are no less worthy or attractive even if you never fetch a perfectly flat, taut belly. My kangaroo pouch says imperfection is a-ok.
We are not vain for wanting more attractive bellies, but we are foolish if we equate our worth with our bellies. They are simply parts of us that grew new, amazing life; we can’t give back our children and we can’t get back our bellies. Nevertheless, we can still move forward.
We can IMPROVE and we can ACCEPT our “mother figures.”
Below are descriptions of the 8 exercises. You can also watch an annotated demonstration of each exercise HERE. The password is adailyroutine. Clearly, I’m not destined to be a video star, but hopefully the explanations suffice. If you need more help, email me.
I’ve curated these exercises from many sources, as well as tweaked them to suit my preferences, so feel free to do the same.
Try to complete all the reps of each exercise 2x daily for a total of two sets. However, if you don’t have the time, one is fine.
1. Pelvic Party (20 rep)
Start with a pelvic party. You can also call this a “pelvic floor release and contract with lower rib breathing and lower abdominal activation,” but that’s a mouthful. It’s probably best known as the Kegel.
- Lie on your back with knees bent, and put your hands on your ribs.
- Breathe in. Try to feel the air gently push your ribs outward. If you can’t feel anything, put one hand on your chest and the other on your belly. Breathe in again. Where do you feel the most movement? Try for a movement in your lower ribs. You’ll still feel air in your chest and abdomen, but you also want to feel your rib cage move. You should feel your pelvic floor gently lower as you breathe in.
- Now breathe out. Feel your ribs compress a little. At the same time, lift your pelvic floor in and up. Your transverse abdominis might co-contract. This is good. If it doesn’t, actively contract it by pretending the two sides of your hips are trying to meet along your bikini line. It’s a party after all; let the transverse abdominis come along.
- Do not lift the lower rib cage off the floor or arch your lower back.
Accurately contracting your pelvic floor and transverse abdominis takes some practice. I highly recommend having a physical therapist check your ability to contract. In the meantime, pick the visual that works for you. Check out 10 Kegel Cues and 5 Transverse Abdominis Cues for some choices.
Do 20 reps and vary the length of the contraction. Sometimes hold for endurance and sometimes pretend like your vagina is trying to jump on the table, so to speak. There should be a certain flow, but if it’s too regimented, it’s not much fun.
Level 1: Supine
Level 2: Sitting
Level 3: Standing
Level 4: Squatting or Lunging
2. The Lock (15 reps)
Don’t pop, just lock. This physical therapy staple is splendid stabilization practice. Your torso “locks” while your legs try to unlock this stability.
- Lie on your back with knees bent. Again, neither press nor arch the lower back and don’t let your upper back or chest pop up. Instead, think of locking your torso into place before starting the movement.
- While maintaining the lock in your abdomen, slowly lower one knee out to the side, return, and then lower the other knee. The goal is to lift the pelvic floor and brace the abdominals before lowering each leg. Keep your hips level.
- If you can easily and slowly lower your knees, progress the exercise into a heel slide.
- Heel Slide: Slide one leg out straight. Return. Repeat with the other leg.
- If that is easy, move on to the single leg heel drop. If that is too easy, straighten the leg. If taking both legs off the floor causes your back to arch too much, feel free to imprint the spine into a pelvic tilt (flat against the floor). This will take you out of neutral, but that’s fine.
Level 1: Knee to the side
Level 2: Heel slide
Level 3: Single bent leg drop
Level 4: Single straight leg drop
3. Dynamic Side Balance (15 reps/side)
In this exercise, your arm and leg are movement arms trying to knock you off balance. Your abs keep you from falling over. You work all the abdominal muscles as you try to maintain balance without changing the position of the spine.
- Lie on your side with your head resting on your bottom arm.
- Start with your knees bent, but you will work up to straight legs. Make sure you create a straight line from your head through your pelvis.
- Move your top arm backward as you move your top leg forward. Then, move your top arm forward as you move your top leg backward.
Level 1: Bent legs
Level 2: Lower leg bent
Level 3: Both legs straight
Level 4: Make leg and arm circles
4. Push-ups (15 rep)
The push-up has an awesome literal name. You push up.
Traditional push-ups vigorously work the abdominals. However, you don’t want to overload the pelvic floor or lose the abdominal contraction. Therefore, figure out what incline is right for you. Start at the wall. Move to a countertop, then an ottoman, and eventually onto the floor with legs bent or straight.
- No matter the incline, place your hands slightly wider than shoulder-width apart. Maintain a controlled line from your head through your feet (if on an incline) or through your knees (if on the floor).
- Inhale as you bend your elbows and lower yourself as far as you can maintain control.
- Exhale as you push yourself back up (i.e. on exertion). Lift the pelvic floor at the same time.
Level 1: Wall
Level 2: Counter-top
Level 3: Ottoman
Level 4: Floor on knees
5. Hippy Dippy Side Plank (10 reps/side)
Some diastasis recti specialists worry about overworking the outer abdominals and overloading the pelvic floor. Too much pressure on the pelvic floor is bad, but so is ignoring the obliques, especially the internal oblique, which often co-activates with the transverse abdominis. A dynamic side plank is a great way to work these oblique muscles. Pick the level that challenges without overloading your abdomen or pelvic floor.
- Balance on your side. Position your bent elbow underneath your shoulder. Keep a straight line from your elbow through your shoulders to your pelvic floor.
- Slowly dip your hip. Inhale as you dip, and exhale as you lift the hip. Don’t tip backwards or forwards.
- If you start holding your breathe or lose the contraction, make the exercise easier by decreasing or removing the dip.
Level 1: Both knees bent with shallow dip
Level 2: Deeper dip and bottom leg straight
Level 3: Dip with straight legs
6. Funky March (15 reps)
I call this a Funky March because it combines a knee lift and hold with a pelvic tilt. This combination works the muscles isometrically and concentrically.
- Stand with your feet hip width apart.
- Lift one knee and pretend you are trying to push the knee down with the other hand. Maintain the isometric contraction for a beat. You should feel your abdominals contract. Switch legs and hands.
- Then, with both legs on the ground, do a pelvic tilt. A pelvic tilt involves tucking only your pelvis without moving your torso or legs. Make sure to untuck the pelvis before moving on to the next march.
7. Wall Wings and Squat (15 reps)
Practically every postpartum exercise routine includes some variation of a wall squat. I added the wall wings because they help stretch tight chest muscles and provide a little bit of instability for the abs to work against. This exercise gets harder as you go deeper into the squat. And it gets really hard if you lift one leg at a time in a controlled wall march.
- Squat with your knees approximately shoulder width apart and your back resting against a wall. Press your lower back into the wall to create a pelvic tilt for stability.
- Bring your hands to your ears with bent elbows, as if your arms are wings.
- Inhale and move your elbows together, while keeping your hands next to your ears.
- Exhale (feel the abdominal contraction) and try to touch the wall with your elbows.
Level 1: Shallow squat
Level 2: Deeper squat
Level 3: 90 degree squat
Level 4: Lift one leg at a time
8. The Vortex (30 seconds)
The vortex is a yogic mountain pose. I call it The Vortex because I want you to pretend a vortex above your head is trying to suck you in. That sounds hokey, but try it. As the vortex pulls on you, ground yourself to the floor. Or, you could just think of it as a mountain pose, but the effect isn’t quite the same.
- Stand tall with your feet shoulder width apart (You can also press a pillow or Pilates ball between your thighs).
- Straighten your arms above your head and pretend like the vortex is sucking you up.
Those are the 8 exercises. Again, they aren’t magic. They aren’t the only 8 you can do, but they are a good start. Play around with the movements. Pay attention to how much control you have over your abdomen. And, if these are too easy, move on. Pick up some weights. Try a crunch or a plank. Maybe even get someone to show you how to deadlift. Movement is play, not prescription. The only way to learn how your body will respond to exercise is by giving it a go. So, let’s go.
Re-watch the Annotated Video (password: adailyroutine)
Print a Reference List
Thanks for reading and watching. More questions? I can be reached at firstname.lastname@example.org.
- Daniel Brauman, “Diastasis Recti: Clinical Anatomy,” Plastic and Reconstructive Surgery, November 2008, Volume 122, Issue 5. ↩
- “At gestational week 35 the mean IRD was 64.6 mm (SD 19.0) and ranged from 22.1 mm to 126.0 mm at rest on measurement 2 cm below the umbilicus, with a prevalence of DRA of 100%” from Patricia de Mota et al. “Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain,” Manual Therapy, February 2015, Volume 20, Issue 1. ↩
- Liaw Lih-Jiun et.al, “The Relationships Between Inter-Recti Distance Measured by Ultrasound Imaging and Abdominal Muscle Function in Postpartum Women: A 6-Month Followup Study,” Journal of Orthopaedic and Sports Physical Therapy, 2011, Volume 41, Issue 6. ↩
- Gertrude M. Beer et.al, “The Normal Width of the Linea Alba is Nulliparous Women,” Clinical Anatomy, September 2009, Volume 22, Issue 6. ↩
- D.R. Benjamin, A.T.M. Van de Water, and C.L. Peiris, “Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review,” Physiotherapy, March 2014, Volume 100, Issue 1. ↩
The Linea Alba
- V. Schumpelick and A.N. Kingsnorth, eds., Incisional Hernia, Berlin: Springer, 1999: 34. ↩
- Ibid., 54. ↩
- Ibid., 87. ↩
- Garry Gillis, “Contracting Muscles Stiffen Their Aponeuroses,” The Journal of Experimental Biology, March 2010, Volume 213, Issue 4. ↩
- M.F. Sancho, A.G. Pascoal, P. Mota, and K. Bo, “Abdominal Exercises Affect Inter-Rectus Distance in Postpartum Women,” Physiotherapy, September 2015, Volume 101, Issue 3, pp. 286-91. ↩
- PG Fernandes da Mota, AG Pascoal, K Bo, “Prevalence and Risk Factors of Diastasis Rectus Abdominis from Late Pregnancy to 6 Months Post-Partum, and Relationship to Lumbo-Pelvic Pain,” Manual Therapy, February 2015, Vol. 20, No. 1 ↩
- Adamants Arampatzis, Kiros Karamanidis and Kirsten Albracht, “Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude,” The Journal of Experimental Biology, August 2007, Volume 210. ↩
- B.F. Miller et al., “Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps muscle after exercise,” The Journal of Physiology, September 2005, Volume 567, Part 3. ↩
- V. Schumpelick and A.N. Kingsnorth, eds., Incisional Hernia, Berlin: Springer, 1999: 66. ↩
- D.R. Benjamin, A.T.M. Van de Water, and C.L. Peiris, “Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review,” Physiotherapy, March 2014, Volume 100, Issue 1. ↩
- Cynthia M. Chiarello, J. Adrienne McAuley, and Erin Hartigan, “Immediate Effect of Active Abdominal Contraction on Inter-Recti Distance,” Journal of Orthopaedic and Sports Physical Therapy, Vol. 26, Issue 3, pp. 177-183 ↩
- J. DeLancey and R. Hartman, “Operations on the Abdominal Wall,” The Global Library of Women’s Medicine, 2008 ↩
- Another argument for splinting as necessary for “healing” has to do with compressing tendons: “Alternatively, they could more uniformly stress a healing area of the tendon in a controlled manner, and thereby stimulate healing once an injury has occurred.” Although this version of healing does seem more plausible, DRA is still not a strain or break. ↩
- M.F. Sancho, A.G. Pascoal, P. Mota, and K. Bo, “Abdominal Exercises Affect Inter-Rectus Distance in Postpartum Women,” Physiotherapy, September 2015, Volume 101, Issue 3, pp. 286-91.↩
- Paul Hodges, “Transversus Abdominis: A Different View of the Elephant,” British Journal of Sports Medicine, 2008, Volume 47, Issue 12. ↩
- Indeed, “the deep, thick layer of connective tissue [the dorsal fascia of the internal oblique muscles] is inseparably fused with the anterior fascia of the transversus abdominis muscle.” That said, it is the “deepest” of the three lateroventral abdominal muscles and covers a lot of ground. It is also an important respiratory muscle. As “far as the level of the costal cartilage of the ninth rib, the posterior lamina consists almost exclusively of the aponeurosis of the transversus abdominis muscle,” but below the level of the costal cartilage of the 9th rib “the posterior lamina is then composed of the transverse fascia, the transversus abdominis muscles and the dorsal sheet of the aponeurosis of the internal oblique muscle.” Quotes from V. Schumpelick and A.N. Kingsnorth, eds., Incisional Hernia, Berlin: Springer, 1999: 51–53. Does any of this matter? Not really. The main point is the anatomy of the linea alba and the rectus sheath is complicated. ↩
- see footnote 3 ↩
- Kari Bo, Bary Berchmans, Siv Morkved, Marijke Van Kampen, eds. Evidence Based Physical Therapy for the Pelvic Floor, Second Edition. Elsevier, 2015: 115–116. ↩
- Ibid. ↩