Diastasis Recti Abdominis (DRA) is a specific condition involving the widening of the midline of the abdominal wall. It is a common occurrence, especially for individuals who have been pregnant, and it directly affects the structural integrity of the front of the core.
Defining Diastasis Recti Abdominis
Diastasis Recti Abdominis describes the separation of the left and right sides of the rectus abdominis muscle, commonly known as the “six-pack” muscles. These muscle halves are typically joined along the midline by a band of connective tissue called the linea alba. The condition is not a hernia, as the muscle and fascia remain intact, but rather a widening and thinning of this central connective tissue.
The linea alba stretches and loses its tension, creating a gap between the two muscle bellies. This separation is measured as the inter-recti distance (IRD). While the degree of separation can vary, a gap that measures wider than two centimeters, or approximately 20 to 25 millimeters, is generally considered to be DRA.
Severity is often informally measured by the number of finger widths that can be placed into the gap when the abdominal muscles are contracted. This separation can occur anywhere along the midline, from below the breastbone (xiphoid process) down to the pubic bone, though it is often widest near or above the belly button.
Causes and Primary Risk Factors
The primary mechanism that leads to the development of Diastasis Recti Abdominis is a sustained or excessive increase in intra-abdominal pressure. This internal pressure pushes outward against the abdominal wall, straining the already taut linea alba. Late-stage pregnancy is the most common cause, where the expanding uterus creates mechanical stretching while hormonal changes, such as the release of relaxin, cause connective tissues to soften.
The condition occurs in nearly all pregnant individuals by the third trimester. Other factors that increase the risk include having multiple pregnancies, which subjects the abdominal wall to repeated stretching, and carrying multiple babies, such as twins or triplets. Advanced maternal age, typically over 35, is also associated with a higher likelihood of developing DRA.
Increased intra-abdominal pressure outside of pregnancy can also be a cause. This may result from chronic straining, excessive weight gain leading to obesity, or performing abdominal exercises incorrectly. High-strain movements, such as traditional crunches or sit-ups done with poor form, can overload the midline and contribute to the separation. Genetic factors influencing the strength and quality of the connective tissue can also play a role in a person’s susceptibility to the condition.
Identifying the Physical Signs
The most common and observable sign of DRA is a visible bulge or “pooch” in the abdomen, which often persists long after weight loss or childbirth. This protrusion is the internal organs pushing against the weakened linea alba. The appearance is often described as looking “still pregnant” or having a distended belly.
A tell-tale sign is the phenomenon of “doming” or “coning” when the abdominal muscles are engaged. This occurs when a person attempts to sit up from a lying position, coughs, or strains, causing a ridge to appear down the center of the stomach. Beyond the cosmetic concerns, DRA can lead to functional issues like lower back pain and poor posture because the core muscles are unable to stabilize the spine effectively. The separation can also compromise the deep core unit, leading to associated issues like pelvic floor dysfunction and urinary incontinence.
A simple self-check can help identify the presence and extent of the separation. To perform this, a person lies on their back with knees bent and feet flat on the floor. The person then places their fingers perpendicularly on the midline of the abdomen, either just above, at, or just below the navel. While gently lifting the head and shoulders slightly off the ground, the fingers press down to feel for a gap between the two firm edges of the rectus abdominis muscles. A gap wider than two finger widths warrants further evaluation.
Management and Repair Strategies
The initial approach to managing Diastasis Recti Abdominis is typically conservative, focusing on specialized physical therapy and core strengthening. The goal of this rehabilitation is not necessarily to close the gap but to restore tension and function to the linea alba and the entire deep core. Physical therapy programs emphasize exercises that engage the transverse abdominis, which is the deepest abdominal muscle, to act as a natural corset.
Proper breathing techniques, such as exhaling on exertion while contracting the deep core, are taught to manage intra-abdominal pressure during movement. It is important to avoid exercises that significantly increase outward pressure on the midline, such as traditional sit-ups, crunches, planks, and heavy lifting, until the core integrity has improved. Temporary support garments, such as abdominal binders or splints, may also be used to provide external compression and support during early recovery or activity.
If conservative measures fail to improve symptoms or if the separation is particularly severe, surgical repair may be considered. Surgical options generally involve a procedure called plication, where the thinned and stretched linea alba is folded and sutured together to restore the integrity of the abdominal wall. This is often performed as part of an abdominoplasty, commonly known as a “tummy tuck,” which also removes excess skin and fat.
Minimally invasive techniques, such as laparoscopic or robotic-assisted surgery, are also used to perform the plication with smaller incisions. Surgery is typically reserved for individuals with persistent, significant functional symptoms or a very wide separation that has not responded to at least six to twelve months of dedicated physical therapy.