Mind the Gap (Part 1): Diastasis Recti Abdominis

As curated social media images expand, stories of going from postpartum body to model abs are everywhere. They are compelling and hopeful. They are also incomplete. They do not reflect most experiences, and they do not answer many of the lingering questions about diastasis recti abdominis.

What is diastasis recti abdominis and why do we care?

Diastasis recti abdominis (DRA) is a widening between the two sides of the rectus abdominis, often called the six-pack muscle. This separation can create a visible bulge through the abdomen, especially during effort. DRA is not limited to pregnancy, but this discussion focuses on pregnancy-related changes. By the third trimester, nearly 100% of pregnant people demonstrate a DRA, often defined as a separation greater than 2 cm below the umbilicus (da Mota). After delivery, the appearance of the abdomen often improves as the inter-recti distance (IRD) narrows and the tissue adapts. For many, concern starts with appearance. The postpartum abdomen does not match cultural expectations of a flat stomach. Beyond aesthetics, DRA has historically been linked to concerns about long-term dysfunction in the body. As physical therapists, we assess DRA as part of a bigger picture. We are interested in how the abdominal wall coordinates with the diaphragm, pelvic floor, and back. These systems often change during pregnancy and postpartum (Lee 2008). DRA is frequently addressed when people present with:

• Low back pain

• Pelvic floor dysfunction

• Pelvic pain

• Urinary incontinence

  
  

Some studies show higher rates of DRA in people seeking care for abdominal or pelvic symptoms (Spitznagle, Parker). However, this does not mean DRA causes these conditions.

What does the research actually say?

Recent prospective studies using ultrasound challenge the assumption that DRA predicts pelvic floor dysfunction or low back pain. Findings suggest:

• No clear relationship between DRA and low back pain

• No difference in symptoms at one year postpartum based on DRA status

• A possible protective role of DRA during pregnancy in some cases

These are population-level findings. Individual experiences still vary widely.

DRA during pregnancy

A large prospective study found no differences in pelvic floor function or urinary incontinence between those with and without DRA during or after pregnancy (Bø).

Interestingly, individuals with DRA in the second trimester demonstrated:

• Higher resting pelvic floor tone

• Greater pelvic floor strength and endurance

• Lower BMI and higher levels of general physical activity

DRA postpartum

At six weeks postpartum, those without DRA were actually more likely to present with pelvic organ prolapse greater than Stage 2 (Bø). Other findings include:

• No relationship between DRA and low back pain at 6 or 12 months postpartum (da Mota, Sperstad)

• Severity of DRA does not predict pain intensity (Parker)

Heavy lifting more than 20 times per week may increase risk of persistent DRA, while factors such as age, BMI, delivery type, and general exercise were not strongly associated (da Mota).

At this point, we cannot predict who with DRA will have symptoms that affect daily life.

Looking deeper: it is not just about the gap

Most research focuses on IRD, the width of the separation. However, emerging thinking suggests that function matters more than width. The linea alba is the connective tissue that links all abdominal muscles, including:

• Rectus abdominis

• Internal and external obliques

• Transversus abdominis

Its ability to transfer force and respond to pressure may be more important than how wide it appears (Lee 2016). A wider linea alba that can generate tension may function better than a narrower one that cannot manage load. Think of a taut rubber band versus a slack one. This means we must interpret DRA in the context of:

• Posture

• Movement patterns

• Breathing

• Load management

We still lack clear subgroups explaining why some DRA resolves and others persist, or why symptoms vary so widely.

Hormones, collagen, and variability

Hormones likely play a role in the development of DRA, but they do not fully explain persistent separation after postpartum hormone levels normalize. Breastfeeding has been associated with prolonged DRA in some studies, though this relationship is not well understood (Parker). A cadaver study found differences in collagen fiber orientation in the linea alba of previously pregnant individuals, suggesting structural adaptations that may influence recovery (Axer).

So how do you actually improve DRA?

The Goldilocks principle

Healing requires the right amount of mechanical load. Not too much strain, and not too little.

Like an ankle sprain, tissues need movement and challenge to remodel effectively.

Exercise and movement (More to come in Part 2)

Transversus abdominis training

Targeted activation of the transversus abdominis (TrA) is commonly used in rehabilitation. Research suggests:

• TrA exercises may increase IRD in the short term

• They may improve tension and reduce distortion in the linea alba

• Over time, they may help reduce separation through improved force transfer (Chiarello, Litos)

What about crunches?

Abdominal crunches activate the rectus abdominis and may temporarily decrease IRD. However, they can also increase distortion of the linea alba (Lee 2016). This does not mean they are harmful. It suggests they should be used thoughtfully within a broader strategy.

Movement as a lifestyle

More important than isolated exercises is how you move throughout the day. We want variability and adaptability:

• Reaching

• Lifting

• Rotating

• Walking with arm swing

Limit constant bracing, tight garments, or external supports unless specifically indicated. These may reduce the body’s internal signaling to adapt.

Managing pressure in the system

The abdominal system includes:

• The diaphragm

• The abdominal wall

• The pelvic floor

• The back muscles

These structures work together to manage intra-abdominal pressure.

Helpful strategies include:

• Avoiding prolonged postures that push the abdomen forward

• Improving breathing mechanics

• Addressing overactive pelvic floor muscles

Time matters

DRA is common early postpartum:

• 52 to 60% at 6 weeks

• 39 to 45% at 6 months

• About 33% at 12 months (da Mota, Sperstad)

Most improvement occurs within the first year, but changes can continue up to 24 months (Liao, Coldron).

Practical tips for recovery

1. Nutrition Adequate protein, vitamin C, and hydration support collagen production.

2. Move often Walking, dancing, and rotational movement help the system coordinate.

3. Stand well Stack ribs over pelvis. Avoid gripping through the glutes or chest.

4. Retrain breathing Diaphragmatic breathing and rib mobility support pressure management.

5. Train the abdominal wall Focus on coordinated activation, especially the transversus abdominis.

6. Progress gradually From supported positions to dynamic, functional tasks.

7. Work with a pelvic health physical therapist Individual variability is high. Skilled care helps tailor the plan and progress safely.

Manual therapy and movement-based interventions have shown benefit in improving function and symptoms, even in persistent cases (Wasserman; Kirk).

Final thoughts

The body is adaptable and responsive when given the right inputs. The linea alba, like other tissues, remodels in response to load. We do not yet know the exact formula for optimizing recovery, but we know that variability, progressive challenge, and coordination matter. And while we are at it, maybe the definition of a “normal” postpartum body can evolve too.

References

• Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001;96(2):239-45.

• Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis recti abdominis. Physiotherapy. 2014;100(1):1-8.

• Bø K, Hilde G, Tennfjord MK, et al. Pelvic floor muscle function and DRA. Neurourology and Urodynamics. 2017;36(3):716-21.

• Boissonnault JS, Blaschak MJ. Incidence of DRA. Physical Therapy. 1988;68(7):1082-6.

• Chiarello CM, Falzone LA, McCaslin KE, et al. Exercise and DRA. Journal of Women’s Health Physical Therapy. 2005;29(1):11-6.

• da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors. Manual Therapy. 2015;20(1):200-5.

• Gillard S, Ryan CG, Stokes M, et al. Inter-recti distance and posture. Musculoskeletal Science and Practice. 2018;34:1-7.

• Keeler J, Albrecht M, Eberhardt L, et al. PT management of DRA. Journal of Women’s Health Physical Therapy. 2012.

• Kirk B, Elliott-Burke T. Visceral manipulation and DRA. Case series.

• Lee D, Hodges PW. Linea alba behavior. JOSPT. 2016;46(7):580-9.

• Lee DG, Lee LJ, McLaughlin L. Stability and breathing postpartum. Journal of Bodywork and Movement Therapies. 2008;12(4):333-48.

• Liaw LJ, Hsu MJ, Liao CF, et al. IRD and function. JOSPT. 2011.

• Litos K. Exercise program for DRA. Journal of Women’s Health Physical Therapy. 2014;38(2):58-73.

• Parker MA, Millar LA, Dugan SA. DRA and pain. Journal of Women’s Health Physical Therapy. 2009;33(2):15-22.

• Pascoal AG, Dionisio S, Cordeiro F, Mota P. IRD and contraction. Physiotherapy. 2014;100(4):344-8.

• Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercise and IRD. Physiotherapy. 2015;101(3):286-91.

• Sperstad JB, Tennfjord MK, Hilde G, et al. DRA and postpartum outcomes. Br J Sports Med. 2016.

• Spitznagle TM, Leong FC, Van Dillen LR. DRA prevalence. International Urogynecology Journal. 2007;18(3):321-8.

Looking for Pelvic Floor Physical Therapy in Philadelphia?

If you are experiencing pelvic girdle pain during pregnancy or postpartum pelvic pain, individualized care can make a meaningful difference.  At Hazel Physical Therapy, we provide pelvic floor physical therapy, prenatal physical therapy, and postpartum care in Philadelphia to help you move with less pain and more confidence. Schedule an evaluation to get started.

This post has been adapted from the original post written by Joanna Hess and published on the Beyond Basics Blog.