Separation of the abdominal muscles (diastasis recti)

Short answer: Diastasis recti is a widening of the connective tissue that runs down the midline between the two bellies of the straight abdominal muscle (rectus abdominis). It is present in most women shortly after birth and it recedes considerably over the first year. Structured exercise has been shown to narrow the distance measurably. In the same studies, that anatomical narrowing did not translate into any improvement in the women's day-to-day function. The work is therefore built around the load-bearing capacity of the trunk and the symptoms a woman actually has, rather than around the closing of the gap.

What separation of the abdominal muscles is

Two long muscles run down the front of the abdomen, from the lower edge of the ribcage to the pubic bone. Together they are called the rectus abdominis, the straight abdominal muscle. The two muscle bellies are joined down the middle by a strip of connective tissue called the linea alba, which runs from the ribcage to the pubic bone along the midline. Diastasis recti is the stretching and thinning of that strip, which allows the two bellies to move apart from one another. The distance between them is known as the inter-recti distance.

Nothing here has torn and no muscle has come away from its attachment. The muscles stay where they belong, and the tissue between them has stretched and widened. The idea that the abdomen has split does not describe this picture, because a stretch is what has happened to the tissue. A stretch and a tear differ both in how they behave over time and in what is done about them, so the distinction is worth making at the outset.

The width of the gap is not by itself a diagnosis. An assessment considers how far the midline has opened, and alongside that, whether the strip can hold its tension when load goes through it. Asked to tighten her abdomen, one woman will show a midline that firms up slightly while another will show a midline that sinks in like a trough, and the two can have exactly the same measurement.

What happens along the midline in pregnancy

As pregnancy goes on the uterus grows and pushes the front wall of the abdomen outwards from the inside. That pressure stretches the midline connective tissue slowly. Over the same months, hormonal changes increase the elasticity of connective tissue, and the two effects together move the muscle bellies apart. The widening that appears over a pregnancy is how the body makes room for a growing baby.

After the birth the pressure is gone and the tissue begins to recover. Recovery is gradual, and it spreads over months. During that time an abdomen that feels soft, slack or still full is expected. A misunderstanding takes hold easily at this point: a gap measured a few weeks after birth is the state of a process still under way on the day it was measured, not a settled picture of how things will stay.

How much of a gap counts as separation

The threshold most widely used in clinical practice is a distance of more than two centimetres, measured about three centimetres above the navel. Knowing where that threshold came from changes the weight the number deserves.

Two centimetres is not a biological boundary. It is a cut-off arrived at by agreement, a line that researchers and clinicians settled on so that findings could be compared. Across systematic reviews the thresholds used by different studies vary between two and two and a half centimetres, which makes those findings harder to set side by side. More telling still, a proportion of the measurements taken in healthy adults with no complaint whatsoever already sit above the threshold. A distance wider than two centimetres is therefore not, on its own, a sign of disease.

In practice this means the number helps sort cases into groups, and the decisions come from elsewhere. A woman's programme is built from the symptoms she lives with and the way her trunk behaves under load, rather than from the millimetres recorded on the day.

How the measurement is taken

The measurement is taken lying on the back, with the knees bent and the soles of the feet on the floor. The woman is asked to lift her head and shoulders slightly off the surface. That small movement tightens the muscles and brings the midline into a state where it can be measured. How far the head is lifted changes the reading, so repeat measurements in the same person have to be carried out in the same way each time.

Measuring at one point alone is misleading, because the distance is not the same everywhere along the abdomen. Above the navel, at the level of the navel and below it are measured separately. In some women the gap is marked only above the navel; in others it is wider below. Programmes differ according to that distribution.

Trying this measurement at home is possible and it can give a rough idea of whether there is a gap along the midline. It does not tell you how the tissue behaves under load, at which level the gap is concentrated, or how it relates to the symptoms. A finger measurement taken at home varies with the thickness of the fingers, with how far the head is lifted and with where on the abdomen the hand is placed, so the same abdomen can produce one result at home and another at an assessment. Reporting how wide a gap is turns out to be easier than reporting how that gap behaves when load goes through it. A result obtained at home neither replaces a diagnosis nor can it be used to rule a finding out.

How common it is, and what happens without treatment

Diastasis recti is present in most women shortly after birth and it recedes considerably over the first year. A cohort study that followed women through the period after birth shows this course. This is a common physiological process that settles largely on its own.

That single piece of information leads in two directions. The first is reassuring. A woman with a gap in her abdomen three months after giving birth is not facing something rare or severe. The second direction makes research harder. Spontaneous recovery can muddle the results of studies trying to measure what exercise programmes achieve, because when a woman's gap narrows it is not easy to separate how much of that came from the programme and how much from the body's own course.

Which symptoms may come with it

The subject usually comes up through the appearance of the abdomen. Softness around the navel, fullness towards the front, and a hollow felt along the midline when lying on the back tend to be the first things noticed. Other things can accompany them.

• Continuing pain, or a sense of tiring, in the lower back and the pelvic area.
• A feeling of not being able to hold the trunk together when lifting something heavy, picking the baby up off the floor, or sitting up out of bed.
• A ridge that becomes more prominent along the midline while coughing and sneezing.
• Urinary incontinence, a sensation of downward pressure, or difficulty emptying the bowel, appearing over the same period.

These symptoms are not counted as a direct consequence of the separation of the abdominal muscles. So many changes are happening at once in the period after birth that working out which one relates to what is the job of an assessment. There are women with a wide gap and no complaint at all, and women with a narrow gap who struggle noticeably, which is why an assessment is not run on the measured distance alone. Since the midline of the abdomen and the pelvic floor belong to the same pressure system, the two areas are usually considered together. Where the pelvic floor sits within that system is set out in detail on the what the pelvic floor is page.

Doming and coning

Two appearances along the midline under load are watched for particularly closely. The first is doming, where the midline bulges forwards over a broad area between the ribs and the pubic bone. The second is coning, where a narrow, pointed ridge stands up along the midline.

Both are seen most often at these moments: sitting up from lying on the back, during sit-up type movements, while holding a plank position, when lifting something heavy, while straining on the toilet, and during a hard cough. In all of them abdominal pressure rises quickly.

Neither appearance is read as a sign of damage. The message is plainer than that: the load going through the midline at that moment is more than the tissue can carry. Seeing it is a reason to adjust the movement. Reducing the load, letting the breath run freely instead of holding it, shortening the range of the movement or changing the starting position may all reduce the appearance. Which adjustment works differs from one woman to the next and is found by trying them during the assessment. Learning to look down at her own abdomen and read that feedback is one of the more useful skills a woman picks up within a programme.

Does exercise narrow the distance

Answering this means reading two separate findings together, each of which completes the other.

The finding on the negative side comes from a randomised controlled trial. One hundred and seventy-five women who had given birth for the first time were randomised. One group was given a supervised exercise class once a week for sixteen weeks, along with daily exercises at home. At the assessment carried out six months after birth, the programme had not reduced the frequency of diastasis recti. Measurement in that trial was made by the finger-width method, and a gap of two finger widths or more was counted as diastasis recti.

The finding on the positive side comes from a recent meta-analysis that pooled nine randomised trials and 450 women. In those studies, structured exercise programmes reduced the distance between the two muscle bellies significantly. The mean difference was reported as 8.05 millimetres. Where the programme had been started within the first three months after birth the effect was larger, reaching 10.2 millimetres. This is the most concrete piece of data suggesting that starting early carries an advantage.

The two findings do not contradict one another, because they were not measuring the same thing. The trial standing on its own asked whether the gap crossed the threshold, which is to say how many women had diastasis recti at all. The meta-analysis measured the change in the distance itself, in millimetres. A programme can narrow the distance by some amount and still leave most women above the two-finger threshold, and that is the technical explanation for two results of this kind sitting side by side. Today's data supports a narrower conclusion than either finding alone: the distance narrows to some degree with structured work.

The gap between narrowing and function

The second finding of the same meta-analysis attracts less attention and matters more. While the distance narrowed, the women's scores on a functional disability scale did not differ between the groups. The women who exercised and the women who did not reported the same level of difficulty in daily life.

This is not the same as saying that exercise achieves nothing. The meaning is finer than that. A narrowing of the distance between the abdominal muscles, measured in millimetres, does not automatically change how a woman feels as she goes about her day. A gap that closes does not amount to a load that can be carried.

Several limitations sit behind that result. Variability between the pooled studies was high and the diagnostic thresholds differed from one study to the next, so the trials were not quite measuring the same thing. Follow-up was short, and only four of the nine studies were judged to be at low risk of bias. The functional scale used is not specific to diastasis recti, so it may have missed the difficulty women were actually having, and natural recovery muddling the results remains a further possibility. The evidence has not established that exercise fails to improve function. The studies carried out so far have simply not shown that it does.

What follows from this

Once the evidence is read this way, the aim of the work sets itself. The purpose is not framed as closing the gap along the midline. It is to develop the load-bearing capacity of the trunk and to address the symptoms the woman is living with. A narrowing of the distance may come out of that process, though progress is not measured by it.

Today's evidence does not support promising that the gap will close, and making that promise causes harm in two ways. Where no closure comes, a woman may count herself a failure. Where closure does come and her symptoms carry on, she is left unable to understand why she is still struggling. Tracking progress instead by the weight she can lift, the time she can stay on her feet and the control she feels when she coughs makes both of those misunderstandings less likely.

Within that frame, physiotherapy runs as a learning process in which appropriate load is raised step by step. Using the breath at the moment of effort, managing abdominal pressure, bringing the deep abdominal muscles and the pelvic floor in together, and reorganising everyday movements all belong to it. The programme is written for the individual and reviewed at regular intervals.

The question of sit-ups, planks and press-ups

Two opposing lists circulate on this subject. Some sources treat these movements as strictly off limits and others say there is nothing wrong with any of them. Both positions claim more than the evidence supports.

The more honest approach looks at the response a woman gives to a movement rather than at the name of the movement. If a distinct cone stands up along the midline during a sit-up, if she holds her breath, if she feels a downward pressure, or if her back pain increases afterwards, then that movement is not suitable for that woman on that day. The same movement may become suitable a few months later at a different level of load and with a different technique.

The plank follows the same logic. Supported variations performed against a wall or a raised surface bring far less load than a full plank on the floor. A press-up asks the trunk to be carried as a single unit, which is the detail that raises the load going through the midline. An assessment looks at whether the woman can carry that load without her midline sinking.

A permanent list of banned exercises is easy to hand over and narrows a woman's life for no good reason, because the same movement can be unsuitable one month and manageable the next. The answer comes from how the trunk responds to the movement.

Everyday loads and carrying the baby

In the period after birth the loads that repeat most often turn up at home rather than in a gym. Picking the baby up off the floor dozens of times a day, lifting out of the cot, carrying on one hip, putting the pushchair into the boot of the car and getting it over the door threshold add up to a genuine loading programme for the trunk. Avoiding these loads is mostly not possible, although they can be organised.

• Rolling onto your side and pushing up with your hand when getting out of bed puts less load through the midline than sitting straight up from your back.
• Bending the knees when picking the baby up off the floor, and keeping the load close to the body, reduces how much the trunk has to reach forward to carry it.
• Breathing out slowly at the moment of lifting, rather than holding the breath, limits the sudden rise in abdominal pressure.
• Constipation and straining on the toilet load the midline with repeated pressure, which is why fluid intake and toilet habits are counted as part of the programme.
• Where a cough persists, the cause needs assessing by a physician first.

None of these adjustments means giving up carrying your baby. Carrying a baby is an unavoidable part of daily life and telling a mother to avoid it is not a realistic suggestion. The same work can be carried on in a way that asks less of the trunk.

Abdominal binders, corsets and taping

Postnatal abdominal binders, corsets and various taping applications are sometimes offered with a promise of quick results. The sources this guide rests on do not cover what binders, corsets or taping applications provide in this particular picture, so no claim is made here in either direction, of benefit or of harm. The decision about using any of them is taken in discussion with a physician.

There are women who feel more held together with a binder in the early weeks, and that feeling is real. Support given from the outside may provide temporary comfort. It does not teach the tissue to work on its own under load. Where a support product is going to be used, it belongs alongside work that develops the trunk's own capacity rather than in place of it.

Support recommended by a physician in the first days after a caesarean falls outside this discussion and is used as that physician advises.

Suspected umbilical hernia and the surgical decision

A gap along the midline and a hernia of the abdominal wall are two separate conditions, although they can be present together in the same area. A swelling around the navel that can be felt with the hand, and that becomes more obvious on coughing or straining, may be a sign of a hernia. A hernia is diagnosed by a physician, through examination and, where it is needed, imaging. A physiotherapist does not make that diagnosis.

If you have recently moved to Turkey and are not sure who to see, the usual route begins with the family physician (aile hekimi) at your local family health centre. A swelling that might be a hernia goes on from there to general surgery, which is the branch that assesses and repairs the abdominal wall. Questions bound up with the birth itself, with the caesarean scar or with bleeding go to obstetrics and gynaecology instead. Waiting times differ between the state route and the private one, and which suits you depends on your insurance and your circumstances.

The decision about surgery belongs to the physician in the same way. Cases that call for repair of the abdominal wall form a separate and less common group. Whether a woman needs an operation cannot be settled in a physiotherapy assessment by looking at the appearance of her abdomen or at the millimetres recorded. Where a hernia is suspected, the exercise programme is planned after the physician has assessed her.

Questions about what such an operation involves, how long recovery takes and what results can be expected from it are also asked here, and this page does not answer them. There is no verified evidence behind this guide on surgical outcomes, and those questions belong to the surgeon who would carry out the procedure. Writing them down and taking them to that appointment is more use than an answer read online.

Findings that call for a physician first

The findings below need assessment by a physician before a physiotherapy assessment. They include the following, and the list is not complete; wherever there is doubt, a physician should be consulted.

• A swelling along the midline of the abdomen that can be felt, is painful, and cannot be pushed back in.
• Abdominal swelling accompanied by nausea, vomiting or fever, or abdominal pain that keeps increasing.
• Redness, warmth, discharge or opening at the site of a caesarean incision.
• An unexpected increase in bleeding after birth, or foul-smelling discharge.
• Newly starting urinary or faecal incontinence, burning on passing urine, or a marked sensation of something coming down.
• Back pain that does not settle with rest, wakes you from sleep at night, or grows steadily worse.
• Swelling, redness and pain in one leg.
• Sudden shortness of breath, chest pain or palpitations.
• Severe headache that does not settle with rest, blurring of vision, or newly raised blood pressure.

Some of the findings on that list will not wait. Sudden shortness of breath, chest pain or palpitations, swelling and pain in one leg, a sudden increase in bleeding, and a severe headache with blurred vision or newly raised blood pressure are emergencies and need to be seen the same day rather than at the next available appointment. If you are new to Turkey, it is worth knowing before you need it that every state and private hospital has an emergency department, signposted as acil servis, which takes patients who walk in without an appointment, and that 112 is the number to call for an ambulance. The remaining findings on the list can go to your family physician (aile hekimi) or to the relevant specialist in the ordinary way.

Diagnosis belongs to the physician. Physiotherapy comes in once that assessment is complete and works within the boundaries it draws.

How the assessment is carried out

The assessment opens with taking a history. The questions cover how the pregnancy and the birth went, whether this was a first birth, when in the day the symptoms are worst, and what she is doing when they appear. This is often the longest part of the appointment and it sets the direction of the programme.

An examination of the trunk follows. The posture of the abdomen, the position of the ribcage and the way the breath moves the trunk are observed. The midline distance is measured above the navel, at its level and below it, separately. After the measurement, the thing that really matters is how the midline behaves under load: the woman is asked to sit up, to cough or to lift a weight, and the midline is watched for doming or coning.

Because the midline of the abdomen and the pelvic floor are parts of the same pressure system, the pelvic floor is considered in most assessments as well. An internal assessment is not an automatic step. If one is going to be carried out, what is being looked at is explained beforehand, verbal consent is asked for, and it is not done if the woman does not want it. Assessment is also possible through external observation and functional testing, and those steps usually give enough information to build a first programme. The assessment can be stopped at any stage. Any woman who wants someone with her in the room is welcome to bring one.

At the end of the assessment the measured distance is not handed over as a result in its own right. The findings are considered together with the movements she struggles in and the symptoms that stand out, and the programme comes out of that whole. Progress is followed afterwards by practical measures agreed in that first appointment: how much she can lift without her midline sinking, how long she can stay on her feet before the ache starts, how much control she feels at the moment of a cough, and whether the symptoms she came in with are easing. Having agreed on those measures at the start makes it easier to see what has changed in the time since.

Sessions are one to one and last sixty minutes, and attendance is by appointment. A free fifteen-minute introductory call can be held first, to talk through what would be involved. Consultations can be held in English. The practice is in Evka 3 in Bornova, at Erzene Mahallesi 113 Sokak No: 1/3, in the same neighbourhood as Evka 3 metro station.

Starting late, a second pregnancy and breastfeeding

"It has been two or three years since the birth, so have I left it too late?" is among the questions asked under this heading. There are data suggesting an advantage to starting early, but that does not make starting later pointless. The trunk capacity of a woman who comes years afterwards can be worked on just as it can in anyone else. She has not left it too late.

For women planning a second pregnancy the question takes a slightly different shape. A new pregnancy will stretch the midline again, and there is no avoiding that. That does not mean the pregnancy should be put off. Having worked on the load-bearing capacity of the trunk beforehand may make things easier through the pregnancy and after it. The decision rests with the woman and her physician.

Breastfeeding is not an obstacle to exercise. The intensity of a programme is set with the feeding pattern, sleep and general tiredness taken into account. Where there is any hesitation about exercising while breastfeeding, the decision is made together with a physician. The timing of returning to movement after birth is dealt with separately on the returning to exercise after birth page.

Where to go next in this guide

If urinary incontinence is being experienced alongside the midline gap, the urinary incontinence after birth page sets out in detail what the evidence says about prevention and about treatment. For anyone wanting to know what the pelvic floor does and how its assessment runs, the what the pelvic floor is page is a reasonable place to begin.

How movement is organised during a new pregnancy is covered on the exercise in pregnancy page, and the return to sport and to running is on the returning to exercise after birth page. Appointment and travel details are on the contact page.