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Diastasis Recti and Ab Work

Here is a question I got from a pregnant client of mine. Its a question I get all the time.

I am pretty sure I am starting to have abdominal separation (I notice a buldge above my navel when I do ab work). I was wondering if it was still safe to continue ab work with this condition (i.e., crunches, planks, leg raises, etc).

There are so many layers to this question, I don't know where to start with my answer. The quick answer to the question is:

NO, its not safe to do crunches. Not for your spine. Not for your pelvic floor. And not for your abdominal wall. Regardless of whether you have this condition, i.e. diastasis recti or not! Regardless of whether you're pregnant or not. As for planks and leg raises: It depends. But if you see the bulge, don’t do it!

I think its helpful to write a bit about abdominal separation and ab exercises in general first. And more specifically about crunches, planks and Co. another time.

Diastasis recti aka The bulge
The bulge that you see when doing abominal exercises is indeed a sign of abdominal separation or diastasis recti (DR)  - the separation of the rectus abdominis muscle away from the midline.

The abdominal muscles (rectus abdominis, the inner and outer obliques and the transversus abdominis or TvA) attach to a string of connective tissue in the front of the abdomen. That string of connective tissue reaches from the sternum down to the pubic symphisis. Chest bone to pubic bone.

That string contains the linea alba and a semi-circled line called linea semilunaris on each side of the linea alba. We call this structure the raphe. Raphe loosely translates to cord or, according to an online dictionary, `a seamlike line that connects two similar parts of an organ‘. The raphe then interweaves via a bunch of other connective tissue with the abdominal muscles. (here is a cool blog post by biomechanist Katy Bowman about the connectiveness of tissue in the body generally and about the linea alba specifically)

The raphe is a tendinous cord that is almost bone-like in strength when under the correct tension. When the tension is just right, the raphe is a thin line that connects the abdominal muscles in the front of the abdomen. That gives the abdominal muscles a solid attachment point from which to shorten or contract as well as lengthen. No diastasis recti and a functional core. Great.

Having diastasis recti, however, indicates that the raphe is not under the appropriate tension anymore. It has kind of fizzled out. The abdominal muscles now attach to a flimsy cord and the abdominal muscles have lost one of their anchors and can’t work properly. No so great.

Now it’s also easy for the separation to get worse – with crunches or heavy lifting or a lot of coughing, sneezing, purple pushing during birth, ….(i.e. incorrect abdominal loading) . DR is a set up for back pain or pelvic pain or pelvic floor problems. If it gets really bad, we’re talking about hernias. Really not great at all. 

(Ps: if you want to see anatomical pictures of diastasis recti, just click here or google 'diastasis recti' in google images)

But the twist here is that the abdominal muscles haven’t really been working properly before diastasis recti happened. Your core weakens from diastasis recti but diastasis recti also comes from a weak core.

Why it happens in the first place
Generally, the separation makes its appearance during pregnancy. But the stage was set long before pregnancy. (And diastasis recti can happen to women who've never been pregnant or to men or to children.)

Dianne Lee, a leading Canadian physiotherapist, writes in the introduction of one of her articles about DR:

'Separation of the abdominal muscles is a common condition after some pregnancies, or many years of abdominal loading with poor technique ....

It really starts with our postural habits and how we carry our body through space. A posture with the pelvis and rib cage thrusted forward is one that induces diastasis recti (and a whole bunch of other not so fun stuff) since the abdominal muscles are not loaded correctly. (Watch this video by physical therapist Julie Wiebe talking diastasis recti and alignment of the pelvis and rib cage)

Here is a photo of the typcial pregnancy posture.

pelvis forward (not really that visible, I admit) and rib cage at an angle - the back of the rib cage is tilted back, the front is tilted forward - same what Julie Wiebe is talking about in that video.

I featured my little sister in a past blog post about mindful standing. She shows how to incorrectly load the abdominal muscles via choice of posture. And then she starts to figure out how to stack her body correctly. Check it out here.

Biomechanist, Katy Bowman once wrote on her facebook page that diastasis recti is NOT the separation of the abdominal muscles from the linea alba due to the expanding size of the uterus and abdomen during pregnancy. But instead DR is the separation of the abdominal muscles from the linea alba due to excessive pressure caused by pelvic and rib thrusting and weakness in the deeper abdominal muscle (the TvA).

DR is primarily caused by a malalignment of the rib cage and pelvis. The alignment of those parts matters because this is where the abdominal muscles attach to and where the raphe gets its tension from. And when big parts of our body like the pelvis and abdomen and rib cage aren’t stacked up properly, pressures rise and escape in places that aren’t equipped to deal with excessive pressure over time. So then we're getting diastasis recti or pelvic organ prolapse or hernias. (here is a good Katy Bowman post with illustrations showing the pressure problems)

The growing uterus during pregnancy on top of an already mal-aligned frame is kind of like the straw that breaks the camel’s back. Thats why diastasis recti is such a common side effect of pregnancy.

When our posture of choice is pelvis forward with tailbone tucked under and rib cage thrusted forward we set ourselves up to devoloping diastasis recti. 

Our postural habits and activities determine our alignment and set the stage for diastasis recti. For example:

- wearing shoes with positive heels our whole life
- sitting on our tailbone for the bulk of the day (slouching)
- not walking nearly enough every day and when we walk, not walking in alignment
- never having done a proper squat since toddlerhood
- sucking our bellies in to appear thinner
- not breathing properly
- doing abdominal exercises like crunches or sit-ups excessively and not doing other movements that involve the whole body often enough
- doing exercises with bad technique that resembles our bad posture
- not spending an extended period of time on hands and knees or not being able to achieve a pull-up which indicates a lack of appropriate strength to weight ratio which ultimately indicates a weak core
- thinking that a strong core can be achieved by doing excessive abdominal exercises of all sorts and then doing just that: doing ab exercises in lieu of whole body movement in alignment

While abdominal exercises absolutely have their place and time when done with proper technique, I think it makes much more sense to stop thinking that doing ab exercises gives us a strong core. Instead we should think about how to carry our bodies when sitting, standing, walking, bending over, lifting, hiking, climbing, crawling, dancing, twisting, squatting, playing around, .... and how all this involves our abdominal muscles in a healthy way. The more in alignment, the more ab muscle involvement, the better for your health and ultimately the better for your looks if you care about thatsmiley.

BUT what can I do to restore my core RIGHT NOW?
-Stack your body correctly with pelvis and rib cage in neutral. To find out how, read this Katy Bowman post about stance and this one about rib thrusting.

-Stop sucking in your belly and learn how to contract the TvA muscle

- Start breathing into your rib cage more. Here is a video and more to read about diastasis recti

- Go for a walk today and tomorrow and the day after.

- AVOID or limit activities or movements where you see 'The Bulge' or when you feel increased pressure on your pelvic floor or abdominal wall or diaphragm! Avoiding crunches should be the easy part.

- Oh, and this post I wrote about ab exercises and alignment should be helpful too.

- You can book a session with me, either in person in Ottawa or via skype.

UPDATE: Katy Bowman has come out with her Diastasis Recti book. Click on the image below to get a digital download of it. 






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