During pregnancy, as the baby is developing and the belly grows, what many pregnant women don’t realize is that, to accommodate that growth, changes are occurring not only in the uterus and skin, but all also in the abdominal muscles.
Toward the later stages of pregnancy, continued expansion of the uterus is possible thanks to the linea alba — a line of connective tissue that runs from under the sternum to the pubic bone, and connects the two sides of the rectus abdominis muscles. The linea alba stretches, allowing the baby to have more room than it would otherwise.
It’s really quite phenomenal that a woman’s body is able to do this! However, this increased length in the linea alba can cause a separation between the abdominal muscles that can stick around long after pregnancy. This common separation is termed diastasis recti abdominis. A 2016 study published in the British Journal of Sports Medicine found that about one-third of postpartum women still have diastasis recti 12 months after giving birth.
When the linea alba is lengthened, it can lose it's ability to generate tension and, therefore, its ability to support the abdomen. The connective tissue stretches loses much of its density and thickness, which leads to a very measurable separation between the two sides of the abdominal muscles.
That gap can extend all of the way from the sternum to the pubic bone, or just somewhere along that line. Typically, the largest gap will be around the belly button. In fact, diastasis recti is often a large contributing factor to what some women refer to as a “stubborn” post-baby belly. If your client has diastasis recti, she might think that she looks bloated all of the time, or that she looks “four months pregnant” when she’s really two years postpartum, and despite her efforts, hasn’t been able to change the appearance of her midsection.
Beyond aesthetics, it’s important to note that as the connective tissue of the linea alba becomes stretched, widened, and thinned, it can impair the ability of the abdominal muscles (and entire core system) to do their best work.
With a decrease in support for the core, spine, and potentially, abdominal, and pelvic organs, a postpartum woman will often feel weaker, and may not feel that she can generate as much force as she used to.
If you or your client are unsure if she has diastasis recti, you might find this article on the signs of diastasis recti helpful for starting a conversation with her, and of course, recommending she see a pelvic health physiotherapist for an assessment is key. But before you both stress… don’t stress! Diastasis recti is a very common occurrence with pregnancy and it can heal, and in most women it does heal naturally. And more important than trying to “heal” it by having the two sides meet back up, is to strive to return function to the linea alba.
While there's no exact protocol proven to heal diastasis recti in every woman, that doesn't mean we can't do anything. Here are three things I have found to help hundreds of the women I work with vastly improve their diastasis recti:
Think of alignment as how the body’s joints and bones “stack up” to create posture. While there's no perfect posture, there are certain postures that feel more strong and supported, encourage proper movement patterns, and may lead to better activation of her core muscles. Additionally, other postures may feel less strong and supported, and may not allow your client to activate her core musculature in the same way. For example, if your client is in a chronic “rib thrust” position (in which the bottom of the ribcage is positioned forward and upward, ahead of the torso), the linea alba could be constantly overstretched. With her ribs stacked over her hips, her muscles and connective tissues have the right amount of length and tension for good activation.
Helping your client get her body into good alignment is like the tale of “Goldilocks and the Three Bears.” You don’t want her spine too straight or too curved. You want it to be just right. That “just right” alignment is called the “neutral spine position.” This alignment gets the diaphragm stacked over the pelvic floor muscles to allow for the core stability system to work optimally.
To help your client get into a neutral spine position and proper alignment use these cues:
When your client is healing her diastasis recti, she should use this alignment in all exercises and in daily life where possible, but especially when under load such as when carrying her baby. The photo on the right shows what this alignment looks like when I am standing.
(For guidance on how to teach your client to assess her own diastasis recti, check out this video.)
For your client to support her core in daily life and when exercising, it is extremely important for her to understand how to gain and release tension (contract and relax) her core and pelvic floor muscles.
When the ribs are positioned over the hips, the diaphragm is stacked over the pelvic floor. This helps the pressure system in the core to function optimally. When she inhales, the diaphragm moves downward slightly and the pelvic floor stretches to allow this change in pressure. When she exhales, both the diaphragm ascends and the pelvic floor contracts upward, too.
To help your client improve her core and floor connection, use these cues:
Note: The contraction is very gentle. Your client should think of it as only about 30 percent of her maximum ability of contraction.
Now that you’ve helped your client learn how to do the core and floor connection, it’s important that she use that connection to promote healing of her diastasis recti. We want to encourage exercises in which your client can create good tension in the linea alba but can avoid any bulging, and exercises that are going to challenge her to strengthen her core musculature, but will not cause any harm to her abdominals and pelvic floor. These exercises help to create tension, density, and strength in the linea alba.
For instance, while healing the diastasis, I recommend avoiding exercises that involve facing the belly to the floor (front-loaded positions) such as the push-up, front plank, and bear crawl. The core may not be able to properly handle the pressure and intensity created by these exercises. What’s more, sometimes women feel that they can't control their abdominals during these exercise, since require a high level of core coordination. . Without the requisite core strength and coordination, the belly can easily bulge forward during these front-loaded exercises.Your client may also complain of feeling uncomfortable downward pressure on the pelvic floor.
In addition, exercises such as the v-up and double-leg raise may also create a bulging belly. The bulging can occur when the core isn't able to properly control the intra-abdominal pressure. The pressure from the “load” has to go somewhere and it usually goes outward. This can happen to anyone who doesn’t have proper intra-abdominal control, not just women with diastasis recti.
Below are some of my favorite core exercises for women completing diastasis recti rehab. I love these because I have found these exercises to work really well for many women. Remember to emphasize for your clients the core and floor connection in all of these exercises, exhaling through the toughest part of each exercise. Additionally, with the client’s permission to touch her, you can feel the linea alba and monitor for bulging when adding new abdominal exercises to the program. Over time as her core and floor connection improves, you won't have to constantly cue her as her core and pelvic floor will respond naturally.
Exhale, squeeze the glutes, and lift the hips upwards until the body is in a straight line from shoulders to knees.
Remember, you don't need her to close the gap to be functional. Emphasis is on tension not on the width of the gap. If your client can generate good tension and maintain it through the exercise, then that is fine. However, if your client has a wide or deep gap (more than two fingerbreadths), it is wise to work with a physiotherapist, which we recommend for all postpartum women anyway.
Support your client and be patient with her — and remind her to be patient with herself and stay consistent! By prioritizing proper alignment as well as the core and floor connection in all of her exercises and in daily life, she’ll go a long way toward healing her diastasis recti and improving her core health and function.
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