It’s no surprise that pregnancy can leave a person’s body feeling… different.
But what happens when those abdominal muscles don’t come back together, even though you’ve been putting in the work to strengthen and reconnect?
About 30% of postpartum women will notice a persistent “gap” in between their abdominal muscles at 1 year postpartum.1 This widening and thinning of the connective tissue at the midline of the abdominal wall is called diastasis recti (or diastasis rectus abdominis, “DRA”).2
DRA isn’t a sign that anything is broken - in fact, it’s considered a normal adaptation so that mom’s body can accommodate a growing baby. Some studies show that up to 100% of pregnant people have some degree of widening and thinning of those tissues at the midline of the abdomen (the linea alba) during late pregnancy.3 Even so, it can be frustrating and discouraging when that area doesn’t recover fully after birth, especially for women who are working hard to feel stronger in their postpartum recovery and their baby’s postnatal journey.
Given that persistent DRA is often blamed for postpartum concerns like low back pain, pelvic floor issues, and lingering frustrations with post-pregnancy body image, it’s no wonder that it has become one of the hottest topics in the postpartum-rehab world. Can we prevent it? Why does it resolve in some people and not in others? Can we restore core function after birth even if we have stubborn DRA? What core exercises or ab exercises can heal diastasis recti?
Let’s take a look at what we know about DRA, and what we can do to address it.
What exactly is DRA?
Quick anatomy lesson: there are many layers of muscle in the abdominal wall (from deepest: transverse abdominis, internal oblique, external oblique, and rectus abdominis). Each muscle group is surrounded by layers of fascia, which is a type of connective tissue. The rectus abdominis (also known as the “six pack” muscles) sits closest to the surface, and the fascia that connects the right and left sides of the muscle is called the linea alba.
The linea alba is formed from fascia that wraps around the rectus abdominis and connects to all the deeper layers of the abdominal wall as well.2 A gap of up to 1-2 centimeters between the rectus abdominis muscle bellies is considered normal anatomy and is present in many non-pregnant or postpartum individuals.4 The linea alba that sits between them is strong and flexible, and functions as part of the abdominal wall as we move throughout our day.
Almost every single system in the human body is impacted by pregnancy, but the most visible change happens in the abdomen. As a pregnancy progresses and the baby inside grows, the abdominal wall has to stretch to make room. The muscles all around the abdomen get thinner and broader, and so does the connective tissue that ties the abdominal muscles together. The linea alba performs a spectacular feat of transformation with widening and thinning alongside the muscles to allow space for the baby to grow nice and big at the end of a pregnancy. After birth, when there is no longer a baby filling the space, those muscles slowly return to their pre-pregnancy shape and thickness.
In some postpartum bodies, the linea alba remains widened and thinned, resulting in the aesthetic appearance of a “gap” or a “bulge” right at the midline of the abdominal wall. This can occur at any point along the length of the abdomen from ribcage to pubic bone, and often occurs right around the bellybutton. Most initial recovery happens during the first 8 weeks postpartum, though about 30% of individuals still show signs of it at 1 year postpartum.
Though DRA can occur in any individual regardless of gender, childbearing history, or age, it’s most common in pregnant and postpartum women.3 The jury is still out on whether maternal age, how many pregnancies she’s had, or mode of delivery are risk factors for developing DRA.1
Why does DRA matter?
Have you ever heard the terms “abdominal separation” (“ab separation”), “muscle separation”, or “abdominal split” as they refer to DRA? Those terms paint a picture, don’t they? And not a pretty one!
Those words might lead women to feel that their core is damaged or broken. On top of that, the internet has been flooded with lists of “Do’s and Dont’s” of things you should and should not ever do if you have DRA. For instance, sit-ups are bad. So are planks. And you should definitely never try to carry an infant car seat.
Here’s the good news: you’re not as fragile as all that makes you seem.
First of all, you’re not actually “split” down the middle. The linea alba has widened and thinned during pregnancy, alongside all the other muscles in your core. That stretch was essential to allow your baby to grow. When it comes time for postpartum recovery, muscle changes more quickly than fascia, so that’s part of why you might see a persistent DRA even if your core muscles are getting stronger over time. Even if DRA is persistent, your body can still be strong, supported, and capable of whatever comes your way.
What are the symptoms related to DRA?
Given that DRA is associated with a widening and thinning of the entire abdominal wall, it’s not surprising that many women say that one of their biggest concerns is simply how their postpartum belly looks. Many women report that the presence of stretched ab muscles, with or without a gap between muscle bellies interferes with their self-confidence, mental health, and sexual wellbeing.
A well-functioning abdominal wall is important for stability throughout the entire body. The abdominal muscles play a crucial role in transferring load, stabilizing the spine and pelvis, and supporting our bodies during everyday tasks. It makes sense that it would lead to functional issues like abdominal weakness, low back pain, and even pelvic floor dysfunction.
However, when it comes to functional concerns like low back pain, evidence is mixed. One recently published systematic review showed that 61.5% of studies actually reported no association between DRA and low back pain, while only 38.5% showed a positive correlation5. Several other studies also show minimal connection between presence of DRA and low back pain or pelvic floor dysfunction.6
When it comes to pelvic floor dysfunction and DRA, there may be a correlation between support structure integrity issues such as pelvic organ prolapse and DRA. This might be because both concerns involve some degree of connective tissue laxity, and risk factors might be related to genetic predisposition.7 The evidence linking the two is weak, however, and some studies don’t show a connection at all.8
Women with persistent DRA do show strength deficits when it comes to trunk rotation and flexion, probably because it becomes more difficult to transfer load across the midline when the muscles are farther apart. Though this might not make a difference in terms of longer-lasting pain or ability to perform day to day tasks, it is still worth addressing in order to optimize your core function and strength so you’re ready for whatever life throws your way.
How can I tell if I have DRA?
When we evaluate for DRA, we want to look for 3 elements: width, depth, and tension.9
Width is measured in a variety of ways, but the simplest can be to use fingertips for reference. Using the tips of your fingers, how far apart are the muscle bellies? This number might change between a relaxed state and a contracted state (ie: a crunch or a draw-in activation of the deep abdominals).
Depth refers to how many knuckles deep the area allows before you’re met with resistance. This can provide some insight as to how thin the connective tissue has become.
Tension refers to the quality of the resistance you feel. This is most valuable when used as a comparison between a resting state and a contracted state. Tension can tell us how strong those tissues at the midline are, and may improve over time and training.
Try this:
- While lying on your back with knees bent in a neutral position, feel the width, depth, and tension of the midline of your abdominal wall at the very top, just under your ribcage. This is your point of reference, since it is least likely to be greatly affected by pregnancy. Using the tips of your fingers, feel the width (how many fingers wide or finger widths), depth (how many knuckles deep), and tension (how much resistance do you feel).
- Then move down the midline of your abdomen, feeling for width, depth, and tension all the way past your bellybutton to your pubic bone.
- Now that you have assessed your relaxed baseline, see what happens when you engage your deep abdominal muscles. Exhale as you “draw-in” your abdominal muscles and see how that changes your assessments. Now add a mini-crunch, and assess again.
- Though lying down is usually how assessment and research is conducted, standing up is a more functional posture and can give us more information about how the abdominal wall is really working. Try your assessments again in standing with a neutral spine (pay attention to poor posture), repeating steps 1-3 (without the mini-crunch, of course).
Can DRA be prevented?
At present, risk factors are broad and inconclusive. There may be a connection between connective tissue laxity and DRA, which indicates that there might be a genetic predisposition to persistent DRA.7 Though new research is emerging every year on this topic, it’s not clear at this point if or how we might influence the presence of DRA.
Though we may not be able to prevent it entirely, we can continue to prioritize global strength and functional movement throughout pregnancy and postpartum. Fascia can become stronger just like muscle, though it takes longer to see changes. Emphasizing a deep abdominal “brace” without bearing down or holding breath may set you up for a stronger abdominal wall all around, and therefore a more functional and tense midline, regardless of the width or depth of the linea alba.
Can I “fix” it with the right exercises or exercise program?
The old school approach to DRA with it’s “do’s and don’ts” lists likely set postpartum women up for a weaker core all around. If you’re not moving much, you’re more likely to have back pain. As we have seen in the research, diastasis recti doesn’t necessarily cause lower back pain - the pain you’re having might be more related to a weaker core all around rather than the diastasis recti itself.
There might be a slight benefit to activating the transverse abdominis by “drawing-in” and also some benefit to “curling-up” type exercises.4,9 These two movements impact the linea alba in slightly different ways, and over time the combination reps may stimulate the fascia to strengthen, thus improving the overall function of these tissues.
As you move through each of the diastasis recti exercises and abdominal exercises listed below, pay attention to your starting position. Practice starting each movement with a gentle draw-in of the deep core muscles and pelvic floor. This low-impact movement shouldn’t create any movement in your spine initially - if you notice you’re “crunching” or rounding your spine forward, you might be working too hard. Use proper breathing techniques as you continue any diastasis recti workout.
If you find yourself holding your breath or bearing down to achieve the movement, that can be a sign you’re compensating for tissues that aren’t quite strong enough to manage the load. Watch for a significant bulge outward at the midline that’s pressurized or abdominal pressure to indicate you might need to back off slightly. Make sure you’re feeling strong with each movement before progressing to the next one. Don’t hesitate to contact a professional, physical therapist, or even a personal trainer to get additional advice or support.
What are some examples of the best diastasis recti exercises that might be helpful for DRA strengthening and conditioning?
During pregnancy: quadruped draw-in, quadruped with opposite arm and leg lifts (single-leg), side plank
Early postpartum: supine draw-in, supine hands and knees press, elevated plank, elevated plank with mini-mountain climbers
Later postpartum: seated draw-in, boat pose, dead bug, rotational chop, unilateral weighted squat
The bottom line? Don’t be afraid to use it. As long as you’re engaging your core muscles correctly, not over-straining the weaker areas, and taking deep breaths, core strength has a positive effect. The stronger your core gets, the stronger your diastasis becomes, and the more you’re able to do.
What kind of improvement can I expect?
Muscle building can happen relatively quickly. With a focused exercise routine, you might see changes in the muscles of the abdominal wall somewhere in the range of 8-12 weeks. However, since the linea alba is connective tissue and not muscle, it can take quite a bit longer - up to 1-2 years - before a significant visual change in width occurs.10
It can be discouraging for new moms to be working hard without seeing a visual change. However, as we have seen in the research, the width of the linea alba does not necessarily indicate how strong it is. Assessing changes in tension and depth might offer a better picture of the progress you’re making over time. If you’re not seeing a reduction in width, you might still be making valuable progress.
Treatment strategies vary widely, and evidence is mixed about the “best” approach to exercise based treatment of DRA. Fortunately, there is one thing we can agree on: though it requires a little awareness, don’t let it hold you back.
About the Author
Dr. Samantha Spencer, PT, DPT, is a Medical Advisor with Aeroflow Breastpumps. Dr. Spencer is a physical therapist who specializes in pelvic and perinatal care in the Asheville, NC, area where she offers in-home physical therapy to prenatal & postpartum individuals. She also developed the Strong Beyond Birth 28-Day Course to guide and support moms as they return to exercise, and offers virtual consultations to women everywhere.
Information provided in blogs should not be used as a substitute for medical care or consultation.
References
- Patrícia Gonçalves Fernandes da Mota, Augusto Gil Brites Andrade Pascoal, Ana Isabel Andrade Dinis Carita, Kari Bø. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy. 2015;20(1):200-205. https://doi.org/10.1016/j.math.2014.09.002.
- Hall H, Sanjaghsaz H. Diastasis Recti Rehabilitation. [Updated 2022 Aug 15].StatPearls Publishing;2023. https://www.ncbi.nlm.nih.gov/books/NBK573063/
- Michalska A, et al. Diastasis recti abdominis - a review of treatment methods. Ginekologia Polska. 2018:89;2(97-101) DOI: 10.5603/GP.a2018.0016
- Gluppe S, Engh ME, Bø K. What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Braz J Phys Ther. 2021 Nov-Dec;25(6):664-675. doi: 10.1016/j.bjpt.2021.06.006. Epub 2021 Jul 21. PMID: 34391661; PMCID: PMC8721086.
- Sokunbi G, et al. Is Diastasis Recti Abdominis Associated With Low Back Pain? A Systematic Review. World Neurosurgery. 2023;174:119-125. Doi: https://doi.org/10.1016/j.wneu.2023.03.014.
- Wang Q, Yu X, Chen G, Sun X, Wang J. Does diastasis recti abdominis weaken pelvic floor function? A cross-sectional study. Int Urogynecol J. 2020 Feb;31(2):277-283. doi: 10.1007/s00192-019-04005-9. Epub 2019 Jun 13. PMID: 31197430.
- Benjamin D et al. Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: a systematic review. March 2019;105(1):23-24. Doi: https://doi.org/10.1016/j.physio.2018.07.002
- Bø, K., Hilde, G., Tennfjord, M.K., Sperstad, J.B. and Engh, M.E. (2017), Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourol. Urodynam., 36: 716-721. https://doi.org/10.1002/nau.23005
- Lee D, Hodges P. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. Journal of Orthopaedic & Sports Physical Therapy. 2016 46:7, 580-589. Doi: https://www.jospt.org/doi/10.2519/jospt.2016.6536
- Schleip R, Müller DG. Training principles for fascial connective tissues: scientific foundation and suggested practical applications. J Bodyw Mov Ther. 2013 Jan;17(1):103-15. doi: 10.1016/j.jbmt.2012.06.007. Epub 2012 Jul 21. PMID: 23294691.
