Diastasis Rectus Abdominis
Hi Bestie! This one goes out to all the folks who are pregnant or who have been pregnant because today we’re talking about Diastasis Rectus Abdominis, or DRA. I’m pretty sure every person alive has thought about their abs at some point in life. Social media aggressively tries to tell us how our stomachs should look. It wants our ab skin to be taut enough to show off muscles, but not too taut that we start to look masculine. And on top of all that, it wants us to look that way about two seconds after delivering a human baby.
Have you ever seen Selling Sunset? If not, where have you been? And if so, have you noticed in recent seasons how quickly the women in the cast “get their bodies back” after giving birth and how the rest of the cast is even quicker to tell these new moms how good they look? Now don’t get me wrong, there is nothing inherently bad about telling someone they look good, but the whole thing reminds me of the following two points: 1. The women in this cast are living vastly different lives than most of the world, and they have every possible resource at their disposal to help them look however they please and 2. They must be under extreme pressure to look a certain way—pressure related to their social media presences, pressure related to the show, pressure from their work in which their looks seem to be highly valued by the clientele, and pressure from peers to “bounce back” as soon as possible.
Now, why in the bean did I go on this whole tangent about Selling Sunset? To me, the pregnancy and postpartum aspect of the show is somewhat of a case study in the pressures many of us feel during and after pregnancy (and even before!). It’s not really outwardly spoken about on the show, but then again, are these pressures ever really outwardly discussed in our own lives? We are being fed images and subtext that tells us what our pregnancy and postpartum goals should be, and it is hard to combat this information, when it is rarely outwardly stated. I bring this entire spiel up because I’m going to give you the real, scientifically accurate information on the time it takes to heal after giving birth. I’m going to provide you with the recommendations that are out there, but that providers often fail to mention directly and I’m warning you now that these recommendations hugely differ from much of the information we receive from social media.
To understand DRA, we first need to understand the anatomy of the abdomen, aka your abs! The midregion of the human body is made up of lots of different muscles. These may be referred to as your stomach muscles, your abs, or your core. The muscles of the abdominal region include your internal and external obliques (these help you twist), your rectus abdominis (this helps you do a crunch), and your transversus abdominis (this helps to maintain abdominal wall tension and stabilizes the spine and pelvis prior to movement). All of these abdominal muscles help to provide support and protection to internal organs in the region.
You’re probably most familiar with your rectus abdominis muscle (RA): it’s that friendly muscle that can provide you with a sweet six-pack if you train it enough. If you’re a regular gym-goer or you love yoga, you might also be familiar with the obliques and transversus abdominis (TA). In your abdomen, your deepest core muscle (that is, the muscle furthest inside and closest to your inner organs) is your TA. The muscle most superficial (or closest to the outside of your body) is the RA. The RA is made up of two muscles that run parallel to each other and they are connected by a band of soft tissue called the linea alba (LA). It is important to note that the RA muscles run vertically in the body, connecting the top of the pubic bone with the ribs. Contrastingly, the TA runs horizontally in the body: in other words, its muscle fibers run perpendicularly to those of the RA. This is crucial, because the contraction of the TA creates increased tension on the LA, which helps the RA muscles to function more optimally.
Abdominal muscle layers
Now let’s focus in on DRA. DRA occurs when there is an increased amount of space between the two RA muscles of the abdomen. It often occurs during pregnancy, but can occur due to other causes such as rapid changes in weight, stomach obesity, or poor training techniques with overloading the abdominal muscles.
A variety of symptoms are associated with DRA. These can include low back pain and difficulty navigating rolling or sitting up in bed. It may be especially difficult to sit up from lying while holding an infant due to the RA muscles being in a position that is not optimized for them to perform their function. Many folks are also unhappy with the aesthetics of the stomach following pregnancy and may even experience something called “doming.” Doming occurs during abdominal contraction of the RA muscles when there is thinning of the LA, the RA muscles are further apart than what is considered typical, and the TA is not being contracted at the same time. It looks like the midline of the abdomen is bulging outward, creating a dome-like appearance. Aside from aesthetic concerns, doming is important to avoid since it places unnecessary strain on the system.
During pregnancy, the two RA muscles move apart from one another in order to make space for baby. In fact, one study reported that by the end of a full-term pregnancy (37+ weeks), virtually all folks carrying a baby had DRA (1). Many folks refer to this as a “separation” of the RA muscles, but in reality, even in late pregnancy, they remain connected via the LA. The “separation” that is felt is more accurately described as a thinning of the connective tissue that holds the two RA muscles together. The LA thins which allows the RA muscles to move further apart and create more room for baby to expand into.
Typical abdominal muscle structure versus abdomen with DRA
I am often asked how to prevent DRA and, while much of the time prevention is key, in this case it is a bit more complex. The RA muscles need to shift to make room for the growing baby, so we don’t necessarily want to prevent this natural progression of pregnancy—instead, we want to provide an increased awareness of and improved control of the abdominal muscles. What is most important in cases of DRA is learning how to use the core musculature optimally. This can be trained before, during, and after pregnancy.
This brings us back to the TA muscle. When the TA muscle is engaged, the tension on the LA is increased, and the entire core functions more effectively. What does it feel like to engage the TA? In order to contract the TA, pull your belly button inward toward your spine. Imagine you are pulling your belly in a bit to button a tight pair of pants. When contracting this muscle, you should not be holding your breath. With the TA contracted, you should be able to breathe normally. If you are pregnant, imaging “hugging” your baby with your abdomen.
If you’re still unsure of whether you are contracting the muscle correctly, find your hip bones with your index and middle finger, then move those fingers toward the inside of the bone (aka just slightly toward the belly button) until you feel that your fingers are on a squishy surface, rather than a hard, bony surface. Once there, pull your belly button in. Do you feel that squishy part of your stomach firming up slightly? That’s the TA contracting! If you’re still having trouble, try this out while lying on your back with knees bent and feet flat—it’s easier to feel in this position!
Learning how to properly contract the TA is essential for managing DRA because it helps to prevent doming (2). The correct contraction of the TA musculature is essential for improving symptoms of and appearance of DRA. Further, the TA muscle is an endurance muscle. This means it is made up of mostly slow-twitch muscle fibers and it is best at contracting for long periods of time. Because of this, when training the TA muscle, it is a good idea to focus on long-hold activities. Contracting for half a second and then relaxing will do less good when it comes to this muscle when compared to contracting and holding for 10+ seconds at a time.
So, how long does it take to improve or resolve symptoms of DRA? That depends on a multitude of factors related to age, how many pregnancies you’ve had, what type of birth you had, etc. But, we know from research that the soft tissue generally takes at least 6 weeks to heal (and continues to remodel for a year) and muscles take at least 6 weeks to strengthen (3). When you providers tell you that you can return to sex and exercise at 6 weeks postpartum, know that this does not mean you need to feel like you are back to your “previous self” by that point. Six weeks is still very early postpartum, and the American College of Gynecology actually recommends waiting a whopping 18 months between pregnancies because that is actually how long it takes for the body to recover from pregnancy and childbirth (4). If this shocks you, you’re not alone. Most folks feel like they should be feeling back to “normal” by 6 weeks postpartum, and if they aren’t, something must be wrong with them. To these people, I say: give yourself some grace! It took 9 months to grow a human and it’s not going to take any less than that to recover from growing a human! Not to mention the trauma of childbirth itself. So when we see women on Selling Sunset having zero issues postpartum, remember that we have a curated window into their lives and they are probably facing many of the same issues us “regular folks” face.
If you suspect you may have DRA, your pelvic health physical therapist will be able to check and provide you with exercises to improve symptoms of DRA. Treatment for DRA can consist of core exercises, kinesiotaping, education surrounding safe and unsafe movements/positions, breath work and managing abdominal pressure, biofeedback with a real-time ultrasound, electromygraphic biofeedback, and much more! I’ll dive into these treatments in a later post so that we can talk more about which ones are supported by the current research and which are not as well supported. The thing I want you to take from this chat is that DRA is a very common issue, especially after pregnancy, and it can be addressed with physical therapy, just like any other issue relating to the muscles.
Phew—I feel like I’ve been talking way too much. Any questions?
XOXO,
Your Pelvic Bestie
References:
1. 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, Volume 20, Issue 1, 2015, Pages 200-205, ISSN 1356-689X,https://doi.org/10.1016/j.math.2014.09.002.
2. Lee D, Hodges PW. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther. 2016 Jul;46(7):580-9. doi: 10.2519/jospt.2016.6536. PMID: 27363572.
3. Kubo, Keitaro1; Ikebukuro, Toshihiro2; Yata, Hideaki3; Tsunoda, Naoya2; Kanehisa, Hiroaki1. Time Course of Changes in Muscle and Tendon Properties During Strength Training and Detraining. Journal of Strength and Conditioning Research 24(2):p 322-331, February 2010. | DOI: 10.1519/JSC.0b013e3181c865e2
4. ACOG: https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/01/interpregnancy-care
*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.
