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Postpartum Recovery pt. 2 Diastasis Rectus Abdominis | Image Courtesy of Katherine Hood via Unsplash
Postpartum Recovery pt. 2 Diastasis Rectus Abdominis | Image Courtesy of Katherine Hood via Unsplash

What is DRA?

Diastasis rectus abdominis (DRA, sometimes referred to as Diastasis Recti) is a distortion or thinning of the linea alba which is the midline of the abdomen that connects left and right rectus abdominis muscles together.

Although DRA can be found in both genders, it is more commonly found in females, and more common during pregnancy (66-100% of women have DRA during their third trimester) and can persist through their postpartum periods. About 33% of women continue to have a DRA a year postpartum. It can look like a gap in the midline, “doming” in the midline, or it can even appear as a “pooch,” in the lower abdomen. 

Why Do We Care?

The abdominal muscles and linea alba assist in trunk movement, posture, lumbopelvic stability, breathing, and abdominal organ support. As you can imagine, it can affect those functions when a DRA is present. As movement specialists, we want to make sure you are engaging the muscles and tensing up the fascia of the linea alba appropriately to help prevent low back pain, pelvic girdle pain, and activity-related injuries. 

How to Assess Diastasis Rectus Abdominis?

The best way to measure DRA is through ultrasound.

However, clinically, we use the finger width examination to measure interrectus distance (distance between the left and right rectus abdominis muscles):

  1. At rest: Lie down flat on your back, place two fingers at midline at the top of the abdomen (right below your breast bone) and feel for bulging, sinking in, or other puckering, etc. and assess how the tissue may change as you move your finger down all the way to your pubic bone
  2. Then place your two fingers about 2 inches above the belly button and sink your fingers in a little bit. Perform a gentle neck curl-up (preferably shoulders off the floor). What happens to your fingers? Do they come up out of the abdomen (doming), do they sink in deeper, or can you feel tension build up in the tissue? Now bring your two fingers into your belly button and perform the same thing. Now bring your two fingers about 2 inches below the belly button and perform the same thing and compare how it feels/reacts at the different locations.

Not only are we checking for width and depth of the midline as you curl your neck up, but you are also checking for doming. Ideally, we like to feel the fascia tense as it loads without any distortion. If you are experiencing a gap (i.e. fingers are sinking in), a two-finger width is considered a DRA. If there is doming (fingers popping up and out as you lift your head), it is a sign that there is poor loading of the linea alba and is considered dysfunctional. We try to train to activate the transverse abdominis muscle prior to the movement, and then the rectus abdominis muscles activate to complete the sit-up activity; this way, no doming or sinking occurs. 

diastasis rectus abdominis example 1
diastasis rectus abdominis example 2

Treatment for Diastasis Rectus Abdominis:

The goal of treatment is to create tension in the linea alba to help with the functions of abdominal support and lumbopelvic stability. 

This may help decrease the DRA interrectus distance, but not always. The most important thing is that you know how to implement strategies to decrease the distortion of the linea alba to prevent visceral and musculoskeletal injuries, especially during exercise and sport activities. In our offices, we like to focus on posture, breathing mechanics with activities, connective tissue of the abdominal wall, and targeted muscle strengthening (especially transverse abdominis and multifidus muscles!) to help treat DRA.

  1. Breath mechanics: It’s helpful to exhale before and as you perform an activity, such as getting out of bed, lifting or bending over; this helps engage your transverse abdominis (see #3)
  2. Abdominal wall connective tissue/trigger points: sometimes there are restrictions in the abdominal wall that can hinder our ability to heal from DRA. Pelvic floor physical therapists are trained to help improve the integrity of the skin/connective tissue. But if you don’t have access to a pelvic floor physical therapist, start massaging your abdomen and see how it feels
  3. Transverse abdominis (“TA”) strengthening: The TA is the deepest abdominal muscle and shares fibers with the aponeurosis of the rectus abdominis and linea alba. So when we engage the TA prior to a certain activity, it helps bring the rectus abdominis muscles together without doming and provides stability during activities or exercises. Through this connection, the transverse abdominis has been clinically shown to be beneficial in helping improve the tension of the linea alba, and thus improve function! 
  4. Multifidus strengthening: Strengthening the multifidus (a deep lumbar muscle) also helps strengthen the transverse abdominis muscle. In fact, one study showed that those who had weaker multifidus strength, was associated with poor ability to engage the TA and is a common finding in those with low back pain (Hides et al, 2011)

In Conclusion…

Diastasis rectus abdominis may be common during pregnancy and postpartum periods, but being proactive about it, learning how to breathe with activity, how to engage these muscles now can help optimize the function and help you return to doing the things you love in a safe and pain-free manner. Any questions? Contact us for more info.

 

References:

Cardaillac C, Viellefosse S, Oppenheimer A et al. Diastasis of the rectus abdominis muscles in postpartum: Concordance of patient and clinician evaluations, prevalence, associated pelvic floor symptoms and quality of life. Eur. J. Obstet. Gynecol. 252 (2020) 228-232.

Hides J, Stanton W, Mendis MD, Sexton M. The relationship of transverse abdominis and lumbar multifidus clinical muscle tests in patients with chronic low back pain. Manual Therapy 16 (2011) 573-577. 

Lee D, Hodges PW. Diastasis rectus abdominis – Should we open or close the gap? Musculoskeletal Science Practice. 2017;28:e16.

Lee D. & Hodges P. W. (2016) Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. Journal of Orthopaedic and Sports Physical Therapy 46 (7), 580–589. 

Sperstad et al. Diastasis rectus abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016; 50(17):1092-6. doi:10.1136/bjsports-2016-096065.

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What Our Patients Have to Say

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Testimonial by Fritzette H.

I went to Heather after the birth of my third child. It was lucky, really, that I was referred to her, because my doctor had referred me to a surgeon for a possible hysterectomy or pelvic wall rebuild. Thankfully, I went to Heather before undergoing either surgery, she was able to fix the problem. She has studied extensively in women's health--even written a book about it--and was able to diagnose my problem, suggest a course of treatment (6 weeks), and then follow through with said treatment. By the end, as she said, I was as good as gold. Boy, was it worth it! Though uncomfortable to talk about, much less write about, it is worth getting the word out there. If you have painful intercourse, especially after birth or other trauma, the treatment may be as simple as Physical Therapy (with Heather, of course). I highly recommend her.

-- Fritzette H., 3/24/16 via Yelp!

Testimonial by M.M.

My husband and I were married for 5 years and unable to have intercourse, but I never knew why. After numerous awful experiences at doctor’s offices (where many doctors told me I “just needed to relax”), a surgery that didn’t fix the problem, and a year of owning dilators that didn’t get me anywhere, someone finally referred me to Heather for Physical Therapy. I finally had answers and information from someone who knew exactly what I was dealing with!

Read more: Testimonial by M.M.

Testimonial by R.H.

No one could tell me why I was having pain during sex--sharp pain, not just uncomfortable, pain. I was referred to Heather Jeffcoat after researching several different options. I had seen a specialist who told me physical therapy would not help and my only option was surgery. I really didn't want to go that route, so when we got a referral, I decided to try it--it can't hurt, I thought. I am so glad I did. She diagnosed the problem right away, which was a relief in itself.

To know why I was having pain eased my mind immensely. And to hear that she could fix it without surgery was another relief. She said she could fix the problem in 6 weeks. I think it was actually 4 for me. She was very methodical, and treated me as an intelligent human being capable of participating in my own recovery. I would absolutely recommend her to anyone. She did not try to prolong my session numbers, she worked hard to accommodate my schedule (and the fact that I had to bring a baby to sessions), and she was completely honest the entire time. It is so hard to find someone with these characteristics, much less a professional who is so good at what she does. She has my highest respect.

-- R.H.

Testimonial by Jackie W.

I was in multiple car accidents a decade ago, and I have been to many physical therapists through the years without success. They found the root of my lower back pain problems and after nearly a decade of barely being able to walk I finally can again without pain. They are also the best pelvic floor pts and the only ones who found the connection between my pelvic floor and lower back problems. If you need help with physical pain, they are your answer.

-- Jackie W., 1/19/17 via Yelp!

Testimonial by T.C.

While pregnant with my twins, Heather took care with keeping me on my feet and pain free. She saved my back, my sanity and the holidays! I would recommend her to every “mom” looking to stay on her feet during pregnancy and post-partum.

-- T.C.

Testimonial by R.M., Age 40

I can’t speak highly enough of the theapists at Femina Physical Therapy and how much they have helped me grow, discover, and love my body. I had had painful sex for my entire life, and didn’t know that there was anything that could be done about it. It was at the point where my husband and I were not having sex for MONTHs, because it was just too frustrating, and I hated feeling like I was the ONLY woman out there who had this problem, especially at my age. I finally brought it up to my doctor because I was turning 40 and my husband and I were barely having enough sex to conceive. And she brought up pelvic floor, PT. I didn’t even know this was a “thing”.

Read more: Testimonial by R.M., Age 40

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