In a prior post we discussed the general strategy of addressing diastasis recti abdominis (DRA). As promised, this post will dive deeper into specific strategies for addressing “severe” diastasis via exercise. 

This post will discuss:

• What is Diastasis Recti and how we define “Severe” DRA
• Key principles for starting core exercise if you have “Severe” DRA
• Specific Exercises for “Severe” DRA

What is Diastasis Recti Abdominis? (DRA)

Diastasis recti is the widening and thinning of the linea alba – the central ligament running up and down the abdomen between the sternum and pubic bone. Thinning and spreading of this ligament is a normal result of pregnancy, and should resolve by 8 weeks postpartum back to its normal width of about 2 cm. Some women will have persistent DRA beyond 8 weeks postpartum – this is when it becomes concerning and warrants attention, because it can be related to core weakness, back pain, bladder issues, and other problems. You might self-diagnose DRA by noticing 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 and not getting better. Your provider might diagnose it by having you lift your head and sticking a few fingers into your belly button. (For more detail on DRA download my free PDF here.)

What is “Severe” DRA?

There is no medical consensus on a definition for “mild”, “moderate” or “severe” diastasis. Various studies have defined severity in different ways, but almost always they use the measurement of “inter recti distance” (IRD). IRD is the distance between the 2 sides of the rectus abdominis. Clinically we measure this by feeling for the borders of the muscle when you do a slight curl up. Research studies may use ultrasound imaging to measure the IRD, but this is not as common in clinical practice. The German Hernia Society and the International Endohernia Society have recently proposed defining “mild” as 2-3 cm, “moderate” 3-5cm width, and “severe” as anything over 5 cm width. The female human finger is typically roughly 1cm wide, which is why we tend to speak in finger widths when measuring DRA, but be aware that your finger width may be different from mine or your provider’s. In clinical practice, I generally agree with this categorization, and educate clients with greater than a 5cm IRD that their condition is on the more concerning end of the spectrum (I don’t like to use the frightening term, “severe”). 

For a demo video of how to self-measure your DRA click here.

As a physical therapist specializing in DRA I am concerned not only with the width of the inter recti distance but with the depth of the gap, and the quality of tension in the ligaments and muscles we find there. As I explain to my clients, the tension I can feel in the central ligament (the linea alba) is just as important as the width – maybe more so when it comes to your prognosis for recovery and how we want to start our training. When assessing the depth I typically classify mild as being less than 1.5 cm depth with good tension in the linea alba – I can feel a notable “back” or “bottom” to the hole that feels springy, not soft or mushy. So, if you do a low curl up and can sink 4 fingers more than 2cm down into your midline and you don’t seem to feel a definitive back, you are likely dealing with a more severe DRA.

What to DO?

If you suspect you have a large diastasis and you are at least 8 weeks postpartum, I strongly recommend a consultation with a physical therapist who is skilled and experienced in diastasis recti rehab. (You can book with my team here.)

If the tissue has remained this lax, it is most likely true that, 1. You have genetic factors that increase the laxity of your tissue and impact recovery, 2. Your transverse abdominis and deep core are not automatically turning on postpartum the way they should, and 3. You will need to take more care and a longer timeline for rebuilding your core and returning to exercise in order to prevent injury. This can be frustrating, because one of the most common complaints for women with severe DRA is that they “look pregnant” – the belly remains distended and doesn’t shrink back down. The impulse is to start to exercise aggressively, especially abdominal exercises. However this strategy can actually make things worse instead of better.

Key Principles to Effectively Address Severe DRA:

• Respect healing time

If you have diagnosed severe DRA, you are more than 8 weeks postpartum. This is the time when many women start feeling their strength return, and can tolerate a bit more load through the abdominals. However, if your DRA is severe you must remember that your tissue is NOT healing on the “normal” timeline, and you likely have some muscle inhibition. What your core needs is “REHAB”, not “strength training”. Still, normal healing time for muscle and ligament after injury is more like 11-12 weeks, so from week 8-12 postpartum you still need to keep things relatively gentle, slow and VERY controlled, with a focus on coordinated activation of the entire core including the abdominals. 

• Include all major muscles

Your abdominals include your transverse abdominis, rectus abdominis, internal and external obliques. Of first priority when it comes to DRA is your transverse abdominis (TrA), which tends to be most impacted by the stretching of the abdomen during pregnancy. This muscle attaches to the ribs, the pelvis, and the linea alba. Its primary functions are to protect the organs, to manage intra abdominal pressure, and to coordinate with the diaphragm, pelvic floor and multifidus to stabilize the spine and pelvis, which it does partly by creating tension in the linea alba. It is structured much like a corset around the trunk, and its contraction is compressive – meaning it 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 need to 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 starting from the pubic bone progressing up through the waist toward the ribs, not pushing downward or outward. You should be able to SEE compression happen in the abdominal wall – this indicates a good contraction of the transverse abdominis. (check out an instructional video here) You should NOT see bulging outward in the abdomen, nor should you feel bulging in the vagina. You need to be able to coordinate your pelvic floor, transverse abdominis, and diaphragm (breathe) when you exercise.

• We want to CHALLENGE your core to just the right degree

Muscle, fascia and ligament do not get stronger unless we challenge them. In the early phase (weeks 8-12) exercises should feel easy-moderate, but for many people the challenge feels more mental than physical – it’s the coordination and finding the RIGHT muscles that feels difficult. In a coordinated, effective contraction of the pelvic floor, TrA and diaphragm, you should be able to hold your abdomen compressed and FEEL tension in the linea alba when you touch it with your fingers as you increase the physical load and challenge on your abs. This is the time when we start aiming for the highest level of challenge we can achieve WITHOUT abdominal “doming” or “coning”. Doming and coning describes the visible, significant bulging outward of the middle of your belly when you challenge it, and it indicates that your TrA is not up to the task and has lost the ability to control your abdominal pressure and maintain compression.

• Self assessing movement and challenge level

As you add load and resistance to your core, you need to assess for “doming,” bulging, or any other indicators that you are overdoing it (pain, vaginal pressure, incontinence etc.). You can view a video of “doming” here. You can assess for doming by directly watching your stomach, or by using a mirror or “selfie” video. You can also use your fingers to feel if your abdomen is bulging, or press inward to feel if you are achieving good tension in your linea alba. If at any point you see excessive bulging or feel negative symptoms including pain or pressure, the activity is too challenging and you should not progress in that way, but rather find a modification where you can successfully control your abdominal pressure until the activity can be done without symptoms.

• You should see progress

As you progress your movements, you should feel your core is getting stronger. Symptoms should improve, your IRD should decrease, and your linea alba tension should get better. If this is not the case, it is time for an assessment with a specialized DRA physical therapist. (You can book with us here.)

If are seeing good progress, remember that progressive challenge is key to continued healing. If you only work at an “easy” level of challenge for your abdominals past about 6 weeks of rehab, your progress may stall. We actually need to LOAD the linea alba, transverse abdominis, and other abdominal muscles in order for them to get stronger and more coordinated. At the point where your diastasis is looking mild to moderate (<4cm width and 1.5 cm depth), you should feel the exercises are challenging, and even give you a little muscle soreness. 

Specific Beginner Exercises for Severe Diastasis

Please keep in mind, individual bodies, with their individual strengths, weaknesses, and impairments, may tolerate or benefit from these movements differently. Inidividual assessment is recommended to see what the best positions and movements are for YOU!

1. Diaphragmatic Breathing with Pelvic Floor + TrA Brace (in supine, standing and quadruped): The easiest position to start with is typically backlying (supine) because your core can be truly relaxed, and you can use your hands to feel what your ribs and abdomen are doing. In standing or upright, your postural muscles will already be on to some degree, and you may find it more difficult to achieve the expansion we are after. In Quadruped (hands and knees) you cannot use your hands to feel what ribs or belly are doing, but some people have an easier time relaxing here, as well as finding a neutral spine.

Start lying on your back or sitting upright with your hands on your ribs, or one hand on the ribs and the other on the lower belly.

Inhale, feeling for 360 degree expansion of the ribs and a gentle lengthening of the belly. Feel the pelvic floor lengthen.

Exhale and feel the ribs gently close as you draw the pelvic floor up and in (imagine closing the vagina around a kidney bean and lifting the bean inward), and draw the TrA inward (imagine the abdominal corset drawing inward around the pelvis, lower belly and belly button).

2. Supine Brace + March:   

Lie on your back, knees bent, pelvis and spine in neutral. Inhale to prepare, then exhale and engage your pelvic floor and TrA as you slowly lift one leg off the floor until it reaches table top position (90 degrees at the hip and knee), then lower it. Keep your spine and pelvis absolutely still. Your exhale and brace should last throughout the motion. Your belly should not dome upward. Repeat on opposite side.

3. Seated Lean-Back + Brace:

Sit upright with your knees bent, neutral spine, arms outstretched in front. Inhale to open the ribs and relax the core, then exhale and engage the pelvic floor and TrA as your lean back slowly. Watch your belly for any bulging or doming! Lean back onlly so far as you can maintain a strong, compressed abdomen. Then return to the upright position.

4. Wall Plank + Brace:

Place your hands on a wall, find neutral posture. Inhale to prepare, then exhale and brace your pelvic floor and TrA as you walk your feet back about 24-30 inches from the wall – as far as your can keeping a neutral spin and without abdominal bulging or doming. Hold this position and breathe, inhaling into the ribs and exhaling from the core. Every breath should re-engage the deep core to keep you stable. Start with holding and breathing for about 3-5 breaths 5 times. As your get stronger, increase to 10-10 breaths )30-60 seconds).

5. Shift to Modified Side Plank:

Lie on your side with a netural spine, knees bent, elbow directly under your shoulder propping up your upper body. Inhale to prepare. Exhale and engage your pelvic floor and TrA as you lift the hips, creating a straight line from your head through the ches, waist, hips and knees. Hold this position for 3-5 breaths, re-engaging the deep core on each exhale as above. Watch for excessive doming/bulging of the abdomen.

6. Bonus Stretch: Sidelying Rotation

If you have severe DRA, your other muscles will start to compensate for the weakness in your anterior abdomen. Your lateral abdominals (obliques and TrA) and quadratus lumborum (big spinal muscle) can tighten up causing back pain. Try this soothing stretch to release these tight muscles, along with your pecs and upper back:

Lie on your side with your head supported on a pillow and your knees bent at 90 degrees. Reach your arms out in front of you, with your hands together.
Rotate the upper arm upwards and outwards from your trunk. Try to rotate as far as you can toward the floor, without forcing the shoulder.
Hold and breathe, imagining the shoulder and upper back sinking further toward the floor, the chest opening, and the whole body relaxing.
Note: You can adjust the level at which you rotate by adjusting the angle of your knees.

Give these a try! If you are uncertain if you’re doing them correctly, if they are not making any difference, if you have questions, or if you aren’t sure if you even have “severe DRA”, please come see us! We are experts at helping women like you navigate this frustrating condition and get back to the life you love. Book with us here.

By Dr. Sheri DeSchaaf, DPT