Abdominal Separation and How to Tell if You Have It
Abdominal separation, also known as diastasis recti abdominus (DRA), is essentially a separation of the rectus abdominus (RA) muscles or six-pack muscles, due to a thinning, widening and protrusion of the linea alba and shortening and/or weakening of the abdominal muscles. This can occur during pregnancy and postpartum but it can also show up when there is chronic coughing, repetitive weightlifting or doing exercises incorrectly and show up in both men and women.
Diastasis Recti Abdominus
Anatomy
When you look at the anatomy of the abdomen, it consists of four layers of abdominal muscles with the pair of rectus abdominus being the most superficial and present on either side of the abdomen. This muscle spans from about the fifth rib to the pubic bone. It generally helps with maintaining a vertical or upright position and functions as a flexor for our trunk, bringing the upper half to the lower half of the body.
Image of 4 layers of abdominal muscles courtesy of frontiersin.org
In pregnancy, this set of muscles can begin to slowly separate as the uterus grows in size. It does not always occur right at the belly button and sometimes the separation occurs either above, below or in all three sections of the abdomen. It will also generally get thicker as it gets pushed off to the sides of the body, making it hard to generate the necessary force for core stability. As those muscles widen, the transverse abdominal muscles, which lie deep to the RA, become thinner and also become hard to generate force due to the excessive stretch that is being applied from the growing uterus. The hormone relaxin, which allows for ligament laxity throughout the body to assist with birthing a baby, affects the linea alba and contributes to DRA as well.
In other cases, where DRA stems from other reasons other than pregnancy, the way we manage pressure can be at play. Ideally, when we do an activity, such as lifting a weight, carrying groceries or coughing, there will be an increase in intraabdominal pressure. The goal of our core and pelvic bowel muscles are to help maintain stability in our container even when there is an increase in pressure. However, vulnerabilities can present themselves especially if there is weakness due to a congenital issue, a surgery, scar tissue or just bad mechanics. When that vulnerability is exposed and we do an activity, such as excessive coughing, it can create dysfunction and weakening of core or pelvic bowel muscles and present as abdominal separation over time.
Signs and Symptoms
Symptoms can vary widely from person to person and really depends on the severity and how long it has been present. Some people may actually experience pain in their abdomen, whereas others may have no symptoms at all. The separation could be so minor that it is hardly noticeable and for others it could be quite prevalent creating discomfort and fear of movement due to the level of instability that it presents, sometimes bad enough that it could warrant surgery. In some cases, the seperation could be so bad and thinning of the linea alba so severe that in one instance, I saw the presence of peristalsis, or movement of the small intestines, via the abdomen because there was so much thinning present in her midsection.
The weakness that is present in the abdominal muscles can create lower back pain, pelvic bowel issues, an inability to carry or lift objects as well as lead to poor posture. If one has had DRA in the past, they experience pelvic bowel dysfunction or do a lot of repetitive movements that encourage the separation, they may be at more risk of DRA than someone who has not experienced this before.
Some of the common signs you will see with someone with DRA is what has been classically called doming or coning that is visible when contracting the abdominal muscles. There can also be a lower belly pooch that is evident when standing as well as softness and depth when pressing into the abdomen. Some may experience hip and pelvic pain and encounter pain with intercourse as well as have dysfunctions affecting the bladder (incontinence) or colon (constipation).
So how can you tell?
If you are newly postpartum, you may be really excited about getting back into your pre-pregnancy exercise routine. However, you may have noticed that when you sit up from bed after nursing your baby, there is a little pooch that is popping out in the middle of your belly. Yet, testing too early, such as one week postpartum, may give false results since there is still an excess of fluid present in your body and your uterus is still doing its job of shrinking back to its original size. So waiting until three weeks or more is more ideal to give a better sense of what is occurring.
Or you may be working on your full body planks or doing a deadlift and notice how much your midsection is sticking out no matter how hard you try to engage these core muscles when lifting a weight or your body. In addition, if you do curlups and notice that your belly is creating a breadloaf instead of maintaining a relatively flat surface, this could all be a sign of a possible DRA.
Generally, this would be diagnosed by a medical professional, such as your primary care doctor or physical therapist. Even after getting the diagnosis, you may want to know if the DRA is still present or if the exercises your physical therapist has given you are working. So, it could be beneficial to reassess for yourself and see what progress is being made.
Below is a short video of a quick way to assess for DRA.
But here is one caveat, try not to obsess over the numbers and how wide the gap is. If you are unsure what your norm was before you developed this issue, it is hard to say that you will get to the normative value of 2 fingers width or less if you didn’t have that in the first place. In addition, it is not just the gap you need to be concerned about, but also the depth, which is the integrity of the linea alba. The more you are able to work on increasing the tension in the linea alba the better that the RA muscles are able to shorten and engage. The way your core functions is going to be way more important than the aesthetic of what your belly looks like, however, for some surgery may be a needed option.
It is also important to note that, especially for those who are in the postpartum phase, that DRA may not go away quickly or after the proposed six week window when everything is “supposed” to go back to normal. Dependent on what your postpartum care looks like, such as getting enough rest and minimizing how much you are doing in those first few weeks to allow your uterus to come back to its original size can play a big role in the healing. If you are nursing, the hormone relaxin continues to course through your body in postpartum. As mentioned earlier, it helps maintain ligament laxity, so that laxity can be present through most of your breastfeeding journey. It will continue to affect your linea alba as well as your pelvis and joints, affecting your posture which can worsen the DRA.
Self-Care for Your DRA
So, either your healthcare provider has determined that you have DRA or you have an inclination that a DRA is what is occurring, so what can you do?
I am a big advocate of having someone assess your movement and exercises rather than providing a bunch of exercises to help manage your DRA without assessing YOU. But there are two things you can start doing now that will make a big difference.
Are you breathing?
Not many of us know how often we are holding our breaths. That could be during the stressful moments of new motherhood or during exercise that is asking more of us than we have the ability to handle. The connection of the core spans from the diaphragm to our pelvic bowel. When we are not managing the pressures in our container well, it can negatively impact our stability. Take a moment to place one hand on your chest and the other on your belly. As you take an inhale, notice if your breath travels all the way down to your pelvic bowel or does it stay stuck not wanting to move. As you exhale, do you feel your pelvic bowel draw upwards and your belly move in as the breath exits out your mouth or nose? Many of us are not breathing optimally and shifting how we do this can really impact your DRA. Trying 360 breathing is one way to practice diaphragmatic breathing and you can check it out here.
How are you standing?
Our posture plays such a big role in how we are managing the pressures in our body. When we are not stacked optimally, where our shoulders are sitting on top of our pelvis, we are going to compensate in a lot of ways, from the way we breath to where we maintain stability in our body. Stand up and notice what your feet, knees and pelvis are doing. If one foot is pointed out compared to the other, you have all of your weight on your toes, your knees are locked or your pelvis is forward of the rest of your body they can all greatly impact your core support and make your DRA worse. Play with simple things like finding the weight equally between both feet while they are in parallel, avoiding locking your knees and push your hips back. This may be enough to slowly shift what may be occurring up above.
References: Automatic Assessment of Abdominal Exercises for the
Treatment of Diastasis Recti Abdominis Using
Electromyography and Machine Learning
https://my.clevelandclinic.org/health/diseases/22346-diastasis-recti
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