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Diastasis Recti Abdominis and Pelvic Floor Dysfunction

Original Editor -Deborah Riczo, Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Tarina van der Stockt, Wanda van Niekerk, Momina Masood, Vidya Acharya, Lucinda hampton, Khloud Shreif and Matt Huey

Diastasis Recti Abdominis

Diastasis recti abdominis

Diastasis recti abdominis (DRA) refers to the widening and thinning of the linea alba. This increases the midline distance between the two rectus abdominis muscles, known as the inter-rectus distance (IRD).[1][2] DRA is diagnosed when the IRD exceeds normal values at one or more points along the linea alba.[3][4] It should be noted that this reflects stretching of the linea alba rather than a true 'separation' of the rectus abdominis muscles.[5]

DRA can affect anyone at any age,[6] but it is most prevalent in pregnant and postpartum women.[1] As the uterus expands to accommodate the growing fetus, the rectus abdominis muscles elongate and their angle of attachment alters. Together with hormone-driven changes in connective tissue,[7] this stretches the linea alba, increasing IRD and causing displacement of the abdominal organs and bulging of the abdominal wall.[6] Increased IRD is present in 33% of women by the second trimester,[8] rising through the third trimester, where estimates range from about 66% to 100% near term.[9] It then resolves gradually over the first postpartum year, with prevalence falling to roughly 60% at 6 weeks, 45% at 6 months and around 33% at 12 months.[10]

This page primarily focuses on women, but note that in men, increasing age, particularly from middle age, raised BMI/obesity, smoking, and exercise that exceeds the load-bearing capacity of the abdominal wall (including heavy lifting that excessively increases intra-abdominal pressure), are considered risk factors for DRA.[11][12]

Clinically Relevant Anatomy for DRA

DRA directly involves the muscles whose aponeuroses form the linea alba. Management also addresses the wider "core canister" that regulates intra-abdominal pressure and trunk control. The following structures are therefore clinically relevant.

Structures directly involved:

Wider core canister:

Commonly Associated Diagnoses

Patients are often referred for a related problem rather than the DRA itself. The diagnoses most frequently associated with DRA are low back pain, pelvic pain/dysfunction and hip or groin pain.[13]

Clinical Features of DRA

The hallmark sign of DRA is a visible or palpable bulge or doming along the midline of the abdomen, usually above and/or below the umbilicus. It is most apparent when the rectus abdominis contracts, such as during a head lift or curl-up, and becomes more pronounced with anything that raises intra-abdominal pressure (e.g. straining or exercise that is too demanding for the abdominal wall).[14][15] DRA frequently co-occurs with pelvic floor dysfunction, including stress urinary incontinence and pelvic organ prolapse, particularly in the postpartum period. However, the evidence for a direct relationship is mixed and of low quality.[16]

Assessment for DRA

There is no single agreed cut-off for diagnosing DRA, and reported prevalence varies because studies differ in measurement method, site and criteria. A separation of around 2 cm or more is widely regarded as clinically significant, particularly where a hernia co-exists.[17] Some classifications describe a separation of roughly 2–3 cm as mild, with larger separations considered more severe.[18]

Physical Examination

DRA is usually identified during the physical examination. The patient is positioned in crook lying, and the clinician palpates the linea alba above, at and below the umbilicus, feeling for separation at rest and during a head lift. The finger-width method screens for the presence or absence of a separation but is the least precise approach. A flexible tape measure or callipers give a more precise estimate of IRD. Overall, findings from the clinical examination correlate well with ultrasound imaging.[17][19][20]

Imaging

CT has historically been regarded as the most accurate way to measure IRD, but ultrasound is the most widely used in practice, especially during pregnancy and the postpartum period. CT and MRI give greater anatomical detail and can identify co-existing problems, such as a hernia. However, they are less suitable for routine use as they are more expensive and, in the case of CT, involve exposure to radiation. Shear-wave elastography, used alongside ultrasound, is an emerging technique that also assesses muscle stiffness.[17]

Treatment for DRA

Conservative DRA management centres on education, exercise therapy and physiotherapy. Current thinking focuses on tensioning the linea alba through core activation rather than closing the IRD.

Rehabilitation centres on strengthening the abdominal and pelvic floor muscles. Well-designed programmes can improve rectus abdominis function and quality of life. Core stability training, in particular, can produce greater reductions in IRD and greater gains in quality of life than traditional abdominal exercises, while curl-ups and other targeted abdominal exercises can increase rectus abdominis strength and thickness even where the IRD is unchanged. Integrating pelvic floor muscle training is also valuable. Early low-intensity combined exercise has been associated with reduced pelvic floor pain and modest improvement in DRA, but protocols must always be individualised to the patient.[17]

Several adjuncts may also have a role. Abdominal binders can support comfort and body image. Note that they should not be applied too tightly, as excessive compression directs pressure onto the pelvic floor. Kinesio taping combined with biofeedback-assisted core strengthening may benefit IRD and physical function, and Pilates may reduce IRD and improve abdominal endurance.[17]

Pelvic Floor Dysfunction

Pelvic Floor Anatomy

The 'pelvic floor' refers broadly to the pelvic region and all its contents and associated structures, including the pelvis, pelvic joints, pelvic organs (bladder, uterus, rectum in women), pelvic ligaments, endopelvic fascia, connective tissue, nerves, blood vessels, lymphatic system, external genitalia and pelvic floor muscles. This section focuses on the pelvic floor muscles.

The pelvic floor muscles close off the bony outlet, except for specific openings: the urogenital hiatus, which contains the urethra and vagina in women, and the anal hiatus, which contains the anal canal.

The deepest layer is called the pelvic diaphragm. It is a broad, funnel-shaped sling of fascia and muscle. The muscles of the pelvic diaphragm are the ischiococcygeus muscle (also known as the coccygeus muscle) and the levator ani. The levator ani divides into three muscles: pubococcygeus, puborectalis and iliococcygeus.

Pelvic floor muscles

The middle layer is called the perineal membrane (also known as the urogenital diaphragm). This layer stretches across the urogenital triangle and, in women, houses the urethral and vaginal sphincters. These sphincters close the urethra and vagina, and maintain continence.

The most superficial layer of pelvic floor muscles consists of bulbocavernosus and ischiocavernosus, the paired superficial transverse perineal muscles and the external anal sphincter, which closes off the anal canal.

For more information on these muscles and their function, see: Overview of Female Pelvic Floor Muscle Anatomy and Physiology and Functional Anatomy of the Pelvis.

Types of Pelvic Floor Dysfunction

Pelvic floor dysfunction is broadly divided into two patterns: an underactive (weak or overstretched) pelvic floor, and an overactive (tight) pelvic floor.

Underactivity (weakness/overstretched)

Weakness or overstretching of the pelvic floor muscles can follow pregnancy and birth, and may contribute to pelvic organ prolapse (POP) and urinary incontinence. POP occurs when a pelvic organ descends into the vaginal wall. It has traditionally been classified by the organ involved — cystocele (bladder), rectocele (rectum), uterine prolapse, urethrocele (urethra), enterocele (intestine) and vaginal vault prolapse (after hysterectomy). Increasingly, though, an anatomically-based system is used, describing anterior vaginal wall, posterior vaginal wall and apical prolapse.[21]

Symptoms can include a feeling of heaviness or pressure, a visible or palpable bulge, stress urinary incontinence (leaking with coughing, sneezing, laughing or lifting), and pelvic or low back pain.[22]

Overactive (tightness)

An overactive pelvic floor is held shortened and elevated and cannot relax fully, so it becomes functionally weak. Associated conditions include levator ani syndrome (chronic tension and pain in the levator ani), proctalgia (rectal pain), vulvodynia (chronic vulval pain), dyspareunia (pain during intercourse) and coccydynia (tailbone pain). Symptoms can include pain in the pelvic floor, hips or pelvis; urinary urgency, stress urinary incontinence or incomplete bladder emptying; and painful or difficult defecation and constipation.[23]

Risk Factors for Pelvic Floor Dysfunction

Risk factors for pelvic floor dysfunction include previous pregnancies, episiotomies or perineal tears, pre-existing continence problems, increasing age, forceps delivery, prolonged active pushing during labour and obesity.[24] Even after a low-risk vaginal birth, some overstretching and muscle trauma occurs; this can resolve with time but may require intervention. Other factors that increase load on the pelvic floor include a respiratory history with excessive coughing (e.g. COVID-19, asthma, COPD) and gastrointestinal problems such as IBS or constipation.[25]

Treatment for Pelvic Floor Dysfunction

Management should address pelvic girdle impairments, including trunk and hip range of motion, flexibility, strength and the muscle slings. Core stabilisation exercises can be introduced, with pelvic floor contractions where appropriate (but not if the pelvic floor is hypertonic) and proper breathing strategies during exercise and daily activities. Patient education should cover behavioural factors, anxiety and fear, fluid intake, bladder irritants, and avoiding the Valsalva manoeuvre.

Onward referral may be appropriate, either to a pelvic floor physiotherapist, a urogynaecologist, or back to the referring provider with recommendations.

References

  1. ↑ 1.0 1.1 Dufour S, Bernard S, Murray-Davis B, Graham N. Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: A Delphi consensus study. Journal of Women’s Health Physical Therapy. 2019 Apr 1;43(2):73-81.
  2. ↑ Acharry N, Kutty RK. Abdominal Exercise With Bracing, A Therapeutic Efficacy In Reducing Diastasis-Recti Among Postpartal Females. International Journal of Physiotherapy and Research. 2015Nov;3(2):999–1005.
  3. ↑ Beer GM, Schuster A, Seifert B, Manestar M, Mihic‐Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clinical anatomy. 2009 Sep;22(6):706-11
  4. ↑ Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):580-9
  5. ↑ Hickey F, Finch JG, Khanna A. A systematic review on the outcomes of correction of diastasis of the recti. Hernia. 2011;15(6):607–14.
  6. ↑ 6.0 6.1 Michalska A, Rokita W, Wolder D, Pogorzelska J, Kaczmarczyk K. Diastasis recti abdominis — a review of treatment methods. Ginekologia Polska. 2018;89(2):97–101
  7. ↑ Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1;100(1):1-8.
  8. ↑ Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016
  9. ↑ Skoura A, Billis E, Papanikolaou DT, Xergia S, Tsarbou C, Tsekoura M, et al. Diastasis recti abdominis rehabilitation in the postpartum period: a scoping review of current clinical practice. Int Urogynecol J. 2024;35:491–520.
  10. ↑ Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Sep;50(17):1092-6.
  11. ↑ Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, et al. Classification of rectus diastasis-a proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. 2019 Jan 28;6:1.
  12. ↑ Zhu C, Shen Y, Wang L, Gu Y, Yu X, Wu L, Gu Y, Xu H. Prevalence, risk factors, and adverse outcomes of diastasis of rectus abdominis in men: a cross-sectional study. Hernia. 2024 Nov 27;29(1):31.
  13. ↑ Claus CM, Malcher F, Cavazzola LT, Furtado M, Morrell A, Azevedo M, Meirelles LG, Santos H, Garcia R. Subcutaneous onlay laparoscopic approach (SCOLA) for ventral hernia and rectus abdominis diastasis repair: technical description and initial results. ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 2018;31(4).
  14. ↑ Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-328. doi:10.1007/s00192-006-0143-5
  15. ↑ Michalska A, Rokita W, Wolder D, Pogorzelska J, Kaczmarczyk K. Diastasis recti abdominis — a review of treatment methods. Ginekologia Polska. 2018;89(2):97-101. doi:10.5603/GP.a2018.0016
  16. ↑ Hagovská M, Dudič R, Švihra J, Urdzík P. Relationships of diastasis recti abdominis with stress urinary incontinence and pelvic floor muscle dysfunction in postpartum women. Eur J Obstet Gynecol Reprod Biol. 2024 Oct;301:222-226.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Du Y, Huang M, Wang S, Yang L, Lin Y, Yu W, Pan Z, Ye Z. Diastasis recti abdominis: A comprehensive review. Hernia. 2025 Jul 7;29(1):222.
  18. ↑ Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, et al. Classification of rectus diastasis-a proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front Surg. 2019 Jan 28;6:1.
  19. ↑ Van de Water AT, Benjamin DR. Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): a systematic review of their measurement properties and meta-analytic reliability generalisation. Manual therapy. 2016 Feb 1;21:41-53
  20. ↑ Chiarello CM, McAuley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. journal of orthopaedic & sports physical therapy. 2013 Jul;43(7):495-503
  21. ↑ Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011;4(1):75-81.
  22. ↑ Sanchez EJ, Chen J, Zapata I, Brooks BD. Pelvic organ prolapse (POP) symptom progression and treatment satisfaction from the patients’ perspective. BMC Women's Health. 2025 Apr 11;25(1):173.
  23. ↑ Laurenzana L, Fitzgerald C, Bennis S. Pelvic Pain and Pelvic Floor Disorders in Women: A Physiatrist’s Approach to Epidemiology and Examination. Physical Medicine and Rehabilitation Clinics. 2025 May 1;36(2):311-28.
  24. ↑ Mihretie TB, Mogess WN. Prevalence and associated factors affecting pelvic floor disorder among women in Ethiopia: A systematic review and meta-analysis. PloS one. 2025 Jul 18;20(7):e0328184.
  25. ↑ Riczo D. Diastasis Recti Abdominis and Pelvic Floor Muscle Dysfunction Course. Physiopedia Plus, 2021.
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