In prior posts I described what diastasis recti is, general strategies of addressing DRA, and how we define “severe” vs. “mild” DRA. This post will cover specific strategies for addressing “mild” diastasis via exercise. 

To review, diastasis recti abdominis is the widening and thinning of the linea alba, the long ligament running up the center of the abdomen. To review the definition read my prior post here. You might suspect DRA if you notice a large bulge in your belly when you rise from bed, do crunches, lean backward, or do other ab exercises, or you may just perceive that your core is extremely weak. (For more detail on DRA download my free PDF here.)

Quantification of diastasis recti involves measuring the distance between the two sides of the rectus abdominis, or the “IRD”. While there is no medical consensus on a definition for “mild” or “severe” diastasis, we can generally say that less than 3cm width and 2cm depth is “mild” while  “severe” is anything over 5 cm width and 2 cm depth. See my last post for further explanation, and for a demo video of how to measure DRA click here.

When I assess a client, I’m not only concerned with their physical measurements. I am also concerned with the level of “bother” or concern they have – how is this impacting their life? Just because the measurements are mild doesn’t mean you don’t need to address your core function! A mild diastasis in conjunction with poor core control, pelvic floor dysfunction, poor posture, and poor strength can still certainly contribute to symptoms including back pain, vaginal heaviness, urinary incontinence, even shoulder and neck pain! When a PT checks your diastasis, that should be just one data point in a thorough, whole body examination with the end goal of addressing all your functional concerns and getting you back in action, whatever that means for you. (To experience amazing, holistic PT care book with one of our team members here.)

A Note Regarding Surgery:

Surgery to repair DRA is called abdominal plication, which is usually done as part of an abdominoplasty or “Tummy Tuck”. Not all surgeons will include plication in a “Tummy Tuck”, so make sure you select a surgeon who includes this procedure! Otherwise you are tightening the skin without actually repairing the structural damage, and this may lead to recurrent problems.

There is currenlty no medical consensus or protocol for which clients will eventually need surgery. Some experts feel that if your IRD is greater than 8 cm and not responding to rehab surgical intervention is likely needed, however it is recommended that ALL women with diastasis trial physical therapy for 6 months to 2 years before drawing a conclusion that surgery is needed. While surgery offers correction of the aesthetic factors (loose skin and fat) in addition to structural repair, it is improtant to remember that it does NOT restore your core coordination or strength. It is also seldom covered by insurance as it considered an aesthetic procedure, making it very costly (>$10,000). Surgical repair does require a long recovery period, with any lifting prohibited for at least 6 weeks. So, when you have small children who want to be held, it is not the time to opt for this procedure.

Good news: if your measurements are mild, it is very likely that skilled rehabilitation will allow you to meet all of your goals, given time and effort. Overall, this option will be much less expensive, less invasive, and less traumatic than surgery, which also results in a large scar and can have other complications. If, however, you are not interested in spending the time or energy for rehab and your primary concern is aesthetics and not strength or function, then surgery is something you can consider! 

Key Principles for starting Core exercise with “Mild” DRA

Mild to moderate diastasis has an excellent chance for full recovery WITHOUT surgery! Let’s dive in.

• Respect healing time

If you are less than 8 weeks postpartum, you need to progress gradually out of respect for normal healing timeframes post pregnancy. If you had a vaginal birth and your abs are healing well, adding too much abdominal contraction too soon may actually hurt your healing pelvic floor! If you had a cesarean, you may have altered sensation or pain at the incision – be sure not to aggravate this when starting ab work. Start with standing, back lying, side lying or hands and knees breath training and core activation, coordinating the pelvic floor in your core contraction. Ideally you  employ the guidance of a PT or at least an online program like my Mom Body Rehab program.

• The major muscles

Your abdominals include your transverse abdominis, rectus abdominis, internal and external obliques. Your transverse abdominis (TrA),which attaches to the ribs, the pelvis, and the linea alba and acts like a corset around the abdomen, tends to be most impacted by the stretching of the abdomen. The TrA serves to protect the organs, manage intra abdominal pressure, and stabilize the trunk partly by tensioning the linea alba! It coordinates with the diaphragm, pelvic floor and multifidus to stabilize the spine and pelvis, and its contraction compresses the abdomen and waistline. The pelvic floor and diaphragm are important partners with the TrA and must be included in core training, and particularly diastasis recti recovery.

• Body awareness

You should be able to FEEL what your core and pelvic floor are doing! When you contract your pelvic floor, you should feel tightening and lifting in your vagina and anus. When you contract your transverse abdominis you should feel a gentle compressive activation from the pubic bone up through the waist toward the ribs. This is a DRAWING IN, not a pushing down/out. You should be able to SEE compression happen in the abdominal wall – this indicates a good contraction of the transverse abdominis. (check out my instructional video here https://www.youtube.com/watch?v=SQUo0rYpgUU&t=245s.) You should NOT feel bulging in the vagina with this contraction.

• We WANT to LOAD and CHALLENGE your core

This is particularly important for mild DRA. Muscle, fascia and ligament do not get stronger unless we challenge them. If you only work at an “easy” level of challenge for your abdominals, you will not see progress. We need to LOAD the linea alba, transverse abdominis, and other abdominal muscles in order for them to get stronger and more coordinated. After about 8 weeks pprtm you should feel the exercises are challenging, and even give you a little muscle soreness. You should NOT however notice any increase in pain, incontinence, or any other symptoms – that is an indication they are too hard.

• Self assessing movement and challenge level

Ideally as you add load and resistance to your core, you have some way of self-assessing for any “doming” or bulging. (video of “doming” here https://www.youtube.com/watch?v=lNxqioaElQs) This can be by directly watching your stomach, or gently laying a hand on your belly to feel for bulging. With MILD DRA, it may be helpful to put your fingers right on the linea alba – exhale and activate your core as you press inward just above your belly button,. You should feel something tense and springy about 1 cm in. That means you are tensing your linea alba well! If you see bulging or feel negative symptoms including pain or pressure, the activity is too challenging and you should not progress until the activity can be done without symptoms.

• You should see progress

As you progress your movement you should feel your core is getting stronger, symptoms are resolving, your IRD is getting smaller, and your linea alba tension is getting better. If this is not the case, it is time for an assessment with a specialized DRA physical therapist. (You can contact us to book here.)

Specific Starter Exercises for Mild DRA: 

(PLEASE do not skip the above sections as they may make or break your success with these exercises!)

For this section let’s assume that you are 1. more than 8 weeks postpartum, 2. have medical clearance to exercise, 3. have self-diagnosed a “mild” DRA, and 4. have good awareness as described above of the TrA and pelvic floor. 

I recommend starting with core challenges in a variety of positions including backlying (supine), sidelying, quadruped (hands and knees), and standing. You don’t live life on your back, so your core needs to be challenged in all planes! Below are some of my favorites, but to be sure there are many others you could try as long as you keep in mind the principles above!

1. Supine march to table top: Lay on your back with knees bent, spine in neutral. Feel your belly so you know you are achieving and maintaining compression. Inhale to prepare as you lift one leg to 90-90, then exhale and engage the deep core (pelvic floor and transverse abdominis) as you lift the other leg. Your spine and pelvis should not move and your belly should NOT pop up when your second leg lifts!Hold the legs in table top for several breaths, maintaining some tension in the abs to stabilize the spine, but still allowing the lower ribs and belly to move a little bit on inhale. Lastly, exhale and engage as you lower one leg, then the other. Repeat x10. As this gets easy, you can increase hold time and/or add other leg/arm movements while your legs are lifted.
2. Modified plank: Get on your hands and knees with a neutral spine. Walk your hands out about 12-18 inches, keeping your hips over your knees. Inhale to prepare, then exhale and engage the pelvic floor (PF) and TrA as you shift your body forward keeping your spine neutral and stable – don’t arch or round your back. Hold the plank for 1-3 breaths, again maintaining some tension while letting the lower ribs move, then return to the hips-back position. Once you can do 3 reps holding for 10 breaths (about 30 seconds) with good core/spine control, try lifting the knees into a full plank! Use an exhale and engage as you lift.
3. Side plank variations: Lie on your side with your knees bent and just slightly in front of you, elbow under shoulder. Try to find a long, neutral spine and neck. Inhale to prepare, exhale and engage your deep core (PF and TrA) as you press through your elbow and knee to lift the hips up and forward so they are in line with your head, ribcage, and knees. Hold 1-3 breaths, then lower and repeat. If these are easy, and you can do 10 breaths with good control, try progressing to the top leg outstretched or even a full side plank with feet staggered (one in front of the other).
4. Roll Down: Sit upright with your legs slightly bent in front of you. Inhale to prepare, letting the ribs and abdomen expand. Exhale and strongly engage the pelvic floor as you lean back – WATCH YOUR BELLY FOR BULGING! Roll back as far as you can keeping abdominal compression, sternum open and neck long. When you feel a bit of a shake, roll back up. Repeat x5. Progress by holding and breathing at your shake point, focusing on maintaining that abdominal compressions! (This is how I progress toward sit ups and pilates roll ups.) This is a high load for your pelvic floor, so be mindful of any vaginal symptoms that develop in the following 24 hrs.

If you want a personalized program of exercises just for you, taking into account YOUR abdominal wall and pelvic floor healing, your individual strengths, weaknesses and imbalances, and tailored to YOUR GOALS (running, pilates, crossfit, soccer etc.), please see us in person or by video and we’ll get you off and running! To book an appointment click here. 

For great info on all things “postpartum body”, you can also register for my free online postpartum workshop here.)

In Closing

Remember, these movements are recommended for MILD DRA. With mild DRA, we WANT to challenge the core and tension the linea alba to make it stronger. We WANT you to feel like you are working HARD, but keeping good form, good tension in the abdominal wall, and good breathing mechanics. Don’t be afraid to progress! In order to get stronger, the linea alba must be progressively loaded. Typical ligament healing times are 11-12 weeks, and while there are some hormonal circumstances postpartum that might delay that timeline, if you meet the criteria above you should be okay to progressively load your core with more and more challenging movements. Don’t be afraid to try challenging core movements after about 12 weeks! As long as you feel good awareness and control, you can coordinate your breath, and you aren’t noticing any bulging or other symptoms, the best way to strengthen your core is to challenge it. If you meet all these criteria there should be no specific exercise that is “off limits” (no, not even crunches or roll ups) IF you can do them with good technique and no symptoms during performance or afterwards.

If you are not making the progress you want, you are not seeing the results you want, you have persistent symptoms like back pain, weakness, bladder issues, vaginal heaviness or painful sex, it is time to see a specialized physical therapist. If you simply want more guidance and one-on-one assessment, that is also a great reason to see a specialist! Even one visit may answer your questions and give you the confidence to move forward on your own.

You can contact us now to book with one of our experts in San Diego. Our PTs are experienced in treatment of diastasis recti and can see anyone in California on site or by video, and you can submit your claims to insurance! If you are outside California you will not be eligible for insurance coverage, but we may still be able to help – email Dr. DeSchaaf directly to discuss your situation at sheri@shefitpt.com.