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Diastasis Recti (DR): A Comprehensive Clinical Guide

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1. DEFINITION

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2. ANATOMY REVIEW

• External oblique
• Internal oblique
• Transversus abdominis (TrA)

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3. CAUSES & RISK FACTORS

Primary Causes

Contributing Risk Factors

• Multiparity — cumulative stretching with each pregnancy
• Multiple gestation (twins, triplets) — greater uterine distension
• Macrosomia / polyhydramnios
• Caesarean section — disrupts fascial integrity
• Previous abdominal surgery or hernia repair
• Connective tissue disorders (Ehlers-Danlos, Marfan syndrome) — defective collagen
• Age — collagen quality declines
• Poor posture — increased lumbar lordosis increases anterior abdominal wall loading
• Heavy lifting with Valsalva maneuver — spike in IAP without proper bracing
• Rapid weight gain or loss
• Genetics — familial tendency noted

Hormonal Mechanism (Pregnancy)

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4. CLINICAL FEATURES

Symptoms

Signs

• Palpable gap along midline (above/below/at umbilicus)
• Loss of tension in linea alba on palpation
• Doming or coning of midline on effort
• Reduced ability to generate abdominal tension
• Altered breathing pattern and trunk control
• Increased lumbar lordosis and anterior pelvic tilt

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5. CLASSIFICATION

By Location

By Severity (Lee & Hodges)

Mota et al. Functional Classification

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6. SPECIAL TESTS & ASSESSMENT

A. Self-Palpation / Clinical Finger-Width Test

• Position: Supine, knees bent
• Method: Patient performs a partial curl-up; examiner places fingers horizontally in the midline at 3 points (4.5 cm above umbilicus, at umbilicus, 4.5 cm below)
• Positive: Gap ≥ 2 finger-widths (≥ 2 cm)
• Limitation: Subjective; poor inter-rater reliability; does not assess linea alba tension

B. Ultrasound Imaging (Gold Standard)

• B-mode real-time ultrasound measures IRD at 3 levels
• Taken at rest and during abdominal activation (ADIM — abdominal drawing-in maneuver)
• Also assesses linea alba stiffness qualitatively
• Portable ultrasound now used in physiotherapy clinics
• Advantage: Objective, reliable, safe, dynamic assessment

C. Caliper Measurement

• Tissue depth calipers can measure IRD
• Less common in clinical practice

D. Tape Measure / Ruler Method

• Simple, quick but least reliable
• Used in low-resource settings

E. CT / MRI

• Used for surgical planning, hernia assessment, or when associated pathology suspected
• MRI provides best soft-tissue detail of linea alba morphology
• CT (as shown in the image above) quantifies IRD and can calculate Component Separation Index (CSI)

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7. PHYSIOTHERAPY ASSESSMENT

7.1 Subjective Assessment

• History: Obstetric history, parity, delivery type, onset, duration
• Symptoms: Pain location (LBP, PGP, pelvic floor symptoms), functional limitations
• Aggravating/relieving factors: Heavy lifting, Valsalva, coughing, posture
• Previous treatment: Surgical, conservative, exercises tried
• Goals: Return to sport, exercise, daily function, body image
• Red flags: Signs of hernia, neurological symptoms, severe pain

7.2 Postural Assessment

• Standing posture: Note lumbar lordosis, anterior pelvic tilt, rib flare, shoulder position
• Breathing pattern: Diaphragmatic vs. accessory breathing, breath-holding tendencies
• Abdominal wall resting tone: Visual inspection for protrusion, asymmetry

7.3 IRD Measurement

• Ultrasound (preferred) or finger-width test at supra-, umbilical, and infra-umbilical levels
• Measured at rest and during ADIM (drawing-in maneuver)
• Note: Width alone insufficient — assess linea alba tension/stiffness

7.4 Linea Alba Tension Test (Lee & Hodges)

• During curl-up: palpate linea alba for tension restoration
• Positive tension restoration: Linea alba tightens on activation — good prognosis
• Absent tension: Linea alba remains flaccid — poorer function, may need surgical referral

7.5 Load Transfer Tests

• Active Straight Leg Raise (ASLR) Test: Assesses lumbopelvic load transfer; positive (difficult/painful) indicates compromised force closure
• Single Leg Stance: Observe Trendelenburg, trunk sway, IAP control
• Functional tasks: Rising from supine, carrying loads, stair climbing

7.6 Pelvic Floor Assessment

• Pelvic floor dysfunction is highly co-morbid with DRA
• Assess for stress urinary incontinence, pelvic organ prolapse symptoms
• Refer to pelvic floor physiotherapist if pelvic floor involvement confirmed

7.7 Core Muscle Assessment

7.8 Strength & Functional Testing

• Curl-up (assess IRD change, doming, compensatory strategies)
• Hip hinge, squat, plank (observe IAP management)
• Sport-specific tests if applicable

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8. DIFFERENTIAL DIAGNOSIS

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9. MANAGEMENT

9.1 Conservative (Physiotherapy-Led) — First Line

Phase 1: Protection & Education (Weeks 0–6 postpartum or initial presentation)

• Education: Explain the condition, avoid abdominal coning/doming
• Avoid: Full sit-ups, crunches, double leg raises, heavy lifting, Valsalva maneuver early on
• Log-rolling technique: Teach proper getting out of bed technique (side-lying pivot)
• Abdominal binder/support garment: May reduce symptoms, support posture — use short-term only; evidence for long-term use is limited
• Breathing retraining: Diaphragmatic breathing to restore pressure management
• Posture correction: Address lumbar lordosis, rib flare

Phase 2: Retraining — Deep Core Activation (Weeks 4–12)

• Transversus abdominis (TrA) activation — drawing-in maneuver
• Pelvic floor exercises — Kegel exercises in coordination with TrA
• Diaphragm-pelvic floor coordination — breathing with pelvic floor co-activation
• Multifidus activation — prone/4-point kneeling
• Dead bug exercises — progressive TrA loading with limb movement

Phase 3: Functional Core Loading (Weeks 8–16+)

• Bird-dog progressions
• Bridges — glute bridge, single-leg bridge
• Modified plank (short lever, progressive)
• Hip hinge patterns — Romanian deadlift, good mornings
• Pallof press — anti-rotation core stability
• Sidelying clams, lateral band walks — hip/pelvic stability

Phase 4: Return to Full Activity & Sport (Weeks 16+)

• Higher load exercises progressively introduced
• Running, jumping assessed for pelvic floor response
• Olympic lifts, heavy compound exercises — only when adequate core control demonstrated

9.2 Abdominal Support

9.3 Surgical Management

• IRD > 3–4 cm with significant functional limitation
• Conservative therapy failed (≥ 6 months)
• Associated hernia requiring repair
• Severe cosmetic distress with no functional improvement

Surgical Options

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10. ROLE OF CORE EXERCISES IN DIASTASIS RECTI

10.1 Why Core Exercises Matter in DRA

1. Transversus abdominis (TrA) — circumferential abdominal compression
2. Pelvic floor — inferior support, pressure regulation
3. Diaphragm — superior pressure regulation, respiratory drive
4. Multifidus — segmental lumbar stabilization

10.2 Safe vs. Unsafe Exercises

10.3 Key Core Exercises — Detailed Protocol

🔵 Stage 1: Foundational (Weeks 1–6)

• Supine, knees bent
• Inhale: expand ribcage laterally and anteriorly, pelvic floor descends gently
• Exhale: gentle drawing-in of lower abdomen, pelvic floor lifts
• 3 × 10 breaths daily

• Supine hook-lying
• Gently draw the lower abdomen inward (navel toward spine) without holding breath or flattening the lumbar spine
• Hold 10 seconds, 10 repetitions, 3 sets
• Progress to 4-point kneeling, then standing

• Supine or seated
• Contract pelvic floor (as if stopping urine flow), hold 5–10 seconds
• Relax fully between contractions
• Coordinate with ADIM and exhalation

• Supine hook-lying
• Gently tilt pelvis posteriorly, activating deep abdominals
• Hold 5 seconds, 10 repetitions

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🟡 Stage 2: Progressive Core Loading (Weeks 4–12)

• Supine, arms pointing to ceiling, hips/knees 90°
• Activate TrA and pelvic floor; on exhale extend one arm overhead and opposite leg
• Return without losing neutral spine or allowing IRD to worsen
• 3 × 8–10 per side

• 4-point kneeling
• Neutral spine, activate TrA; extend opposite arm and leg simultaneously
• Hold 5–8 seconds, return slowly
• 3 × 10 per side

• Supine hook-lying
• Engage TrA and pelvic floor, push through heels to lift hips
• Hold 2–3 seconds at top
• 3 × 15 reps
• Progress: single-leg bridge

• Supine, TrA activated
• Slowly slide one heel along the floor until leg straight; return
• 3 × 10 per side

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🟠 Stage 3: Intermediate Functional (Weeks 8–16)

• Knees on floor, forearms down
• Maintain neutral spine, TrA activated, no breath-holding
• 3 × 20–30 seconds
• Progress to full plank only if no doming observed

• Stand sideways to anchor point with resistance band at chest height
• Press band forward with arms extended, hold 3 seconds, return
• Challenges rotational stability without excessive IRD loading
• 3 × 10 per side

• Hinge at hips, maintain neutral spine, activate lats and core
• Teaches proper load management through trunk
• Start with bodyweight, progress to light dumbbells

• Targets hip external rotators and glutes
• Reduces compensatory lumbopelvic movement
• 3 × 15 per side

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🔴 Stage 4: Advanced Return to Function (Weeks 16+)

• Only when IRD is within acceptable range AND linea alba has regained tension
• Monitor for doming; stop if present

• Bilateral or suitcase carry
• Challenges core under real-world load
• Progress weight gradually

• Squats, lunges, deadlifts, overhead press
• All performed with proper breathing mechanics and bracing
• Exhale on exertion to manage IAP

10.4 Principles of Exercise Prescription in DRA

10.5 Evidence for Core Exercises in DRA

• Bø et al. and Lee & Hodges emphasize that activation of TrA narrows IRD on ultrasound in many women
• Kari Bø (2015) systematic review: specific core training can reduce IRD, though evidence for full resolution is limited
• Mota et al. (2015) showed that ADIM and curl-up both reduce IRD, but ADIM produces less doming
• Thabet & Alshehri (2019) RCT: core stabilization exercises significantly reduced IRD and improved functional outcomes vs. control
• Current consensus: individualized, staged core rehabilitation combining TrA, pelvic floor, multifidus, and progressive functional loading is the evidence-based approach

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11. OUTCOME MEASURES

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12. REFERRAL CRITERIA

• IRD > 3–4 cm persisting after 6+ months of conservative management
• Associated hernia (umbilical or epigastric)
• Severe pain or functional disability refractory to physiotherapy
• Patient preference after informed discussion

• Urinary or fecal incontinence
• Pelvic organ prolapse symptoms
• Dyspareunia
• Pelvic pain

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13. PROGNOSIS

• Most women with pregnancy-related DRA improve with appropriate physiotherapy
• Best outcomes seen with early identification and intervention
• The presence of linea alba tension on activation is the strongest predictor of favorable conservative outcome
• Severity of gap alone does not predict functional outcome — tension/stiffness is the key variable
• Without treatment, DRA persists in ~39% of women at 6 months postpartum (Mota et al.)

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Summary Table

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DIASTASIS RECTI ABDOMINIS (DRA)

A Complete Clinical & Physiotherapy Reference

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PART 1: FOUNDATIONAL ANATOMY

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1.1 The Anterior Abdominal Wall

• Containing and protecting abdominal viscera
• Generating and regulating intra-abdominal pressure (IAP)
• Transferring loads between the thorax, pelvis, and lower limbs
• Producing trunk flexion, rotation, and lateral bending

1. Skin
2. Subcutaneous fat (Camper's fascia)
3. Scarpa's fascia
4. External oblique muscle and aponeurosis
5. Internal oblique muscle and aponeurosis
6. Transversus abdominis (TrA) muscle and aponeurosis
7. Transversalis fascia
8. Preperitoneal fat
9. Peritoneum

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1.2 The Rectus Abdominis

• Two vertical, strap-like muscles running parallel to the midline
• Origin: Pubic crest and pubic symphysis
• Insertion: Costal cartilages of ribs 5, 6, 7 and xiphoid process
• Enclosed within the rectus sheath, formed by splitting aponeuroses of the three flat abdominal muscles
• Segmented by three to four tendinous intersections (giving the "six-pack" appearance)
• Function: Trunk flexion, posterior pelvic tilt, IAP regulation, stabilization

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1.3 The Linea Alba — The Core Structure in DRA

• External oblique (most superficial)
• Internal oblique (middle)
• Transversus abdominis (deepest)

Structural Properties

• Composed predominantly of type I collagen (tensile strength) and type III collagen (elasticity)
• Contains elastin fibers allowing stretch and recoil
• Has a three-dimensional cross-weave architecture that provides resistance to tensile, compressive, and shear forces
• Normal width:
  • Above umbilicus: up to 15 mm at rest
  • At umbilicus: up to 22 mm
  • Below umbilicus: up to 16 mm
• The linea alba is an active load-transmitting structure, not merely passive connective tissue

Functional Significance

• Transmits tensile forces across the midline between the two rectus muscles
• Allows efficient co-contraction of all abdominal muscles
• Maintains lumbopelvic stability during movement and loading
• Regulates IAP in coordination with the diaphragm and pelvic floor

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1.4 The Deep Stabilizing System ("Inner Unit")

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PART 2: DEFINITION & DIAGNOSTIC CRITERIA

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2.1 Definition

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2.2 Diagnostic Threshold

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2.3 DRA vs. Hernia

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PART 3: CAUSES & RISK FACTORS

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3.1 Primary Etiological Mechanisms

A. Mechanical Stretching

• Plastic deformation of collagen fibers (permanent elongation beyond elastic limit)
• Widening and thinning of the linea alba
• Lateral displacement of rectus muscles

B. Hormonal Changes

• Relaxin: Remodels collagen, increases ligament/tendon/fascia extensibility
• Progesterone: Further softens connective tissue
• Estrogen: Affects collagen synthesis and cross-linking

C. Elevated Intra-Abdominal Pressure (IAP)

• Obesity (chronic low-grade elevation)
• Heavy lifting (acute spikes)
• Chronic cough, constipation
• Pregnancy (sustained elevation)

D. Collagen Quality Deficiency

• Adequate collagen cross-linking
• Proper type I:III collagen ratio (type I = strength; type III = early repair tissue, weaker)
• Elastin distribution

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3.2 Specific Risk Factors (Detailed)

Pregnancy-Related

Non-Pregnancy Related

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3.3 Pathological Cascade

Mechanical load + Hormonal laxity
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Linea alba collagen fiber elongation and remodeling
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Increased inter-recti distance (IRD)
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Reduced linea alba stiffness and tension
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Impaired force transmission across midline
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Deep stabilizing system dysfunction
(TrA, pelvic floor, diaphragm, multifidus)
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Reduced lumbopelvic stability
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Low back pain + Pelvic girdle pain + Pelvic floor dysfunction

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PART 4: CLINICAL FEATURES

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4.1 Symptoms

Primary Complaint

• Sit-ups or curl-ups
• Rising from lying to sitting
• Coughing, sneezing, laughing
• Lifting or straining

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Musculoskeletal Symptoms

• One of the most prevalent and disabling symptoms
• Mechanism: Loss of deep stabilizing system function → excessive loading on passive structures (lumbar discs, facet joints, ligaments)
• Pain is typically dull, aching, postural; worse with prolonged standing, lifting, transitional movements
• Prevalence: Studies show ~50–70% of women with DRA report LBP

• Pain over sacroiliac joints, pubic symphysis, or general pelvic region
• Mechanism: Reduced force closure of the pelvis due to impaired abdominal wall function; cannot generate adequate tension through posterior and anterior pelvic ligaments
• Worsened by: walking, stair climbing, single-leg stance, rolling in bed

• Difficulty with functional tasks: getting up from bed, carrying children, lifting groceries
• Abdominal wall "gives out" feeling with sustained effort
• Unable to perform traditional abdominal exercises without doming

• Secondary to altered lumbopelvic stability; muscles around the hip work harder to compensate
• Piriformis, tensor fascia lata tightness common

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Pelvic Floor Symptoms

• Leaking urine with cough, sneeze, jump, run
• Mechanism: Impaired IAP regulation; inability to pre-contract pelvic floor effectively

• Sudden urgency with or without leakage

• Bladder (cystocele), rectum (rectocele), or uterine prolapse
• Mechanism: Reduced superior support from abdominal wall increases downward loading on pelvic floor

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General Symptoms

• Pulling or aching sensation at midline
• Worse with activity, coughing, end of day

• Altered IAP dynamics affect gastrointestinal motility
• Visceral contents bulge forward under reduced wall resistance

• Diaphragmatic excursion compromised by altered IAP dynamics
• Accessory muscle breathing patterns develop

• Body image disturbance; women feel their "stomach sticks out" despite weight loss
• Postpartum depression association reported
• Avoidance of exercise or intimacy
• Reduced quality of life

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4.2 Signs (Objective Findings on Examination)

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4.3 Classification Systems

By Location (Three-Level System)

By Severity (Clinical Grading)

Lee & Hodges Functional Classification (2016)

• Type 1: Wide IRD + Good tension → Functional; conservative management suitable
• Type 2: Normal/wide IRD + Poor tension → Dysfunctional; intensive rehabilitation or surgery
• Type 3: Wide IRD + Poor tension + Hernia → Surgical candidate

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PART 5: SPECIAL TESTS

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5.1 Clinical / Bedside Tests

TEST 1: Finger-Width Test (Head Lift Test / Curl-Up Palpation Test)

1. Examiner places index and middle fingers horizontally across the midline at three points:
   • 4.5 cm above umbilicus
   • At the umbilicus
   • 4.5 cm below umbilicus
2. Ask patient to perform a partial curl-up (lift only head and shoulders, chin tucked)
3. Palpate the gap width and tissue tension simultaneously

• Normal: Gap < 2 finger-widths (< 2 cm); linea alba taut
• Positive DRA: Gap ≥ 2 finger-widths (≥ 2 cm)
• Note texture: Taut (tension present) vs. soft/flaccid (no tension)

• Subjective; finger widths vary between examiners
• Does not quantify IRD accurately
• Poor inter-rater reliability
• Does not measure linea alba tension objectively

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TEST 2: Doming / Coning Observation Test

1. Patient supine, knees bent
2. Ask to slowly perform a curl-up
3. Observe the midline for:
   • Dome: rounded protrusion rising along midline (diastasis present)
   • Cone: more acute protrusion (greater IAP spike)
   • Flat midline: normal (no diastasis or well-controlled)

• Doming indicates the linea alba is not resisting IAP effectively
• Any exercise causing doming should be avoided or modified
• Doming is the primary exercise safety guide in DRA rehabilitation

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TEST 3: Linea Alba Tension Test (Lee & Hodges, 2016)

1. Locate the gap by palpation above the umbilicus
2. Place fingertips into the gap at rest
3. Ask patient to perform a head lift / curl-up
4. Assess whether the tissue adjacent to your fingers becomes taut or remains soft

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TEST 4: Active Straight Leg Raise (ASLR) Test

1. Patient supine, legs straight, 20 cm apart
2. Ask: "Try to raise your right/left leg 20 cm off the table without bending the knee"
3. Patient rates effort on scale 0–5 (0 = not difficult; 5 = impossible)
4. Repeat with manual compression applied at ASIS bilaterally (simulates pelvic compression)

• Positive: Difficulty raising leg, heaviness, pain, pelvic rotation
• Positive with improvement on compression: Confirms pelvic force closure deficit (classic in DRA + PGP)
• Assesses the entire lumbopelvic-hip unit, not just diastasis

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TEST 5: Single Leg Stance Test

1. Patient stands on one leg for 30 seconds
2. Observe:
   • Trunk lateral sway
   • Pelvic drop (Trendelenburg sign)
   • Hip hike or use of breath-holding to stabilize

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TEST 6: Heel Slide / Bent Knee Fall Out Test

1. Supine hook-lying, TrA gently activated
2. Slowly slide one heel along the floor until leg straight OR allow one knee to fall out to the side
3. Observe for: lumbar lordosis increase, pelvic rotation, breath-holding, midline doming

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TEST 7: Plank Hold Test

1. Modified plank (knees down initially)
2. Hold for up to 60 seconds
3. Observe for: doming, inability to maintain neutral, breath-holding, pelvis sinking

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TEST 8: Valsalva Stress Test (Cough Test / Jump Test)

1. Ask patient to perform three strong coughs
2. Ask: "Did you leak any urine?"
3. Observe abdominal wall for doming on cough

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TEST 9: Imaging-Based Diagnostic Tests

Ultrasound (Real-Time B-Mode) — GOLD STANDARD

• Most reliable clinical measurement tool
• Transducer placed transversely over midline at three levels
• Measures IRD in mm at:
  • Rest
  • ADIM (drawing-in maneuver)
  • Curl-up
• Also qualitatively assesses linea alba thickness and echogenicity
• Advantages: Dynamic, real-time, no radiation, portable, inexpensive, widely available in physiotherapy practice
• IRD measurement: From medial border of right rectus sheath to medial border of left rectus sheath

MRI

• Gold standard for surgical planning
• Best soft-tissue characterization of linea alba morphology, thickness, collagen integrity
• Assesses hernias, fascial defects, muscle atrophy
• Expensive; not routine in physiotherapy

CT Scan

• Used for surgical planning (abdominal wall reconstruction, hernia repair)
• Component Separation Index (CSI) calculated from CT
• Not first-line for physiotherapy assessment

Caliper Measurement

• Tissue-thickness calipers placed on medial borders of rectus muscles
• Less commonly used; moderate reliability

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PART 6: PHYSIOTHERAPY ASSESSMENT — DETAILED FRAMEWORK

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6.1 Subjective Assessment (Comprehensive History)

Patient Demographics & Background

• Age, sex, BMI
• Occupation (physical demands, prolonged sitting or standing)
• Activity level and sports participation
• Nutritional and hydration habits

Obstetric / Gynaecological History (for women)

• Number of pregnancies (gravida) and deliveries (para)
• Mode of delivery: vaginal vs. caesarean (number of CS, type of incision)
• Gestation at delivery
• Birth weight of neonates
• Instrumental delivery (forceps, ventouse)
• Immediate postpartum complications
• Time since delivery
• Breastfeeding status (prolactin suppresses estrogen; affects collagen quality)
• Menopausal status

Symptom History

• Primary complaint: What brought the patient in?
• Onset: Gradual or sudden? Linked to event (delivery, lifting)?
• Duration: Weeks, months, years
• Location: Where is the bulge/pain/weakness?
• Character of pain: Dull ache, sharp, burning, pressure
• Severity: NRS 0–10
• Aggravating factors: Lifting, coughing, sit-ups, prolonged standing, specific exercises
• Relieving factors: Rest, support garment, posture change
• 24-hour pattern: Worse morning / evening / end of day?
• Functional limitations: What can't you do? Getting out of bed, carrying children, running, exercise

Pelvic Floor Symptom Screening (MANDATORY)

• Urinary leakage: with cough/sneeze/jump (SUI) or urgency (UUI)?
• Frequency of voiding
• Nocturia
• Pelvic heaviness, dragging, or "something falling out" (prolapse symptoms)
• Bowel: constipation, straining, incomplete evacuation, fecal urgency/incontinence
• Sexual function: dyspareunia, reduced sensation
• Pelvic pain

Psychological / Quality of Life Screening

• Body image concerns
• Postpartum depression (Edinburgh Postnatal Depression Scale if appropriate)
• Anxiety related to returning to exercise
• Social participation restrictions

Previous Treatment

• Previous physiotherapy, what was done, outcomes
• Corsets, binders used
• Surgical history
• Medications (NSAIDs, relaxin supplements, collagen supplements)

Goals

• Patient's primary goals (return to running, weight training, pain relief, cosmesis)
• Timeline expectations

Red Flags — MUST EXCLUDE

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6.2 Objective Assessment

Postural Assessment (Standing, Full-Body)

• Lumbar lordosis (increased = anterior pelvic tilt = increases abdominal wall loading)
• Thoracic kyphosis
• Head forward position
• Rib flare (lower ribs flared anteriorly = common in DRA; affects diaphragm position and TrA line of pull)

• Pelvic obliquity
• Asymmetric muscle tone
• Abdominal ptosis (lower abdomen hang)
• Umbilical position/morphology

• Pelvic level
• Shoulder height asymmetry
• Spinal curvature (scoliosis?)

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Breathing Pattern Assessment

• Observed at rest: Chest-dominant vs. diaphragmatic?
• Lateral costal expansion: Adequate bilateral rib expansion?
• Abdominal wall movement: Rises anteriorly (normal) vs. sucks inward (dysfunctional)
• Pelvic floor response to breath: Descends on inhale, lifts on exhale (normal); reversed or absent (dysfunctional)
• Breath-holding tendency: Does patient hold breath for any trunk loading task?

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Visual Inspection of Abdomen (Supine)

• Abdominal contour at rest
• Umbilical morphology
• Surgical scars (CS scar — assess for tethering, pain)
• Abdominal ptosis or asymmetry
• Ask patient to slowly perform a curl-up and observe for doming, coning

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IRD Measurement (Ultrasound Preferred)

1. 4.5 cm above umbilicus
2. At umbilicus
3. 4.5 cm below umbilicus

1. At rest (relaxed supine hook-lying)
2. During ADIM (drawing-in maneuver)
3. During partial curl-up

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Linea Alba Tension Assessment

• Palpate gap with fingertips during head lift
• Record: taut / partially taut / flaccid / absent tension
• Determines conservative prognosis

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Deep Core Activation Assessment

• ADIM with palpation: Place fingers 2 cm medial to ASIS bilaterally; feel for gentle firm swelling (deep fascia tensioning) on drawing-in without global bracing
• Ultrasound: Measure TrA thickness at rest vs. during ADIM (should increase by ≥ 30%)
• Common faults: Global bracing (all muscles contract), breath-holding, posterior pelvic tilt instead of isolated TrA

• Verbal enquiry and symptom questionnaire
• Pelvic floor physiotherapist referral for internal assessment if indicated (PFDI-20, ICIQ)

• Prone: Palpate 2 cm lateral to spinous processes L4/L5
• Ask for gentle heel lift — feel for multifidus contraction
• Ultrasound: Measure resting multifidus thickness (reduced thickness = atrophy)

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Load Transfer Tests

• ASLR test (as described above)
• Hip hinge assessment: Can patient hinge with neutral spine and coordinated breathing?
• Single leg stance
• Step up/down: Observe trunk control and pelvic stability

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Palpation

• Midline gap: width, depth, quality of tissue
• Linea alba texture: firm/fibrous vs. soft/empty
• CS scar (if applicable): mobility, tenderness, adherence
• Lumbar paraspinals: tenderness, hypertonicity
• Thoracolumbar fascia: tightness
• Iliopsoas, piriformis: tightness (common secondary findings)

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Functional Movement Screen (Select Relevant Tests)

• Sit-to-stand: trunk control, breath management
• Squat: depth, knee tracking, trunk upright, IAP management
• Lunge: pelvic stability
• Overhead reach: rib flare, breathing pattern
• Carry: unilateral load management

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Outcome Measures (Baseline and Progress Tracking)

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PART 7: MANAGEMENT — COMPLETE PROTOCOL

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7.1 Conservative Management (Physiotherapy-Led)

Guiding Principles

1. Education first — the patient must understand their condition
2. Linea alba tension restoration is the primary goal — not just gap closure
3. Progressive loading — from deep activation to functional strength
4. No doming rule — any exercise causing doming is stopped or modified
5. IAP management — exhale on effort; never Valsalva
6. Pelvic floor integration — always co-treat pelvic floor
7. Individualize — severity, fitness, goals, postpartum stage all dictate pace

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PHASE 1 — PROTECTION, EDUCATION & NEUROMUSCULAR ACTIVATION (Weeks 0–6)

Education Checklist

• ✅ Explain DRA mechanism in simple terms (show diagram)
• ✅ Why doming is harmful and how to recognize it
• ✅ Log-rolling technique: always roll to side before rising from lying (avoids sit-up motion)
• ✅ Posture correction: neutral pelvis, avoid anterior pelvic tilt and rib flare
• ✅ Avoid heavy lifting early on; if must lift, exhale while lifting
• ✅ Avoid: traditional crunches, sit-ups, double-leg raises, leg press with breath-holding

Abdominal Support

• Tubigrip / abdominal binder: Provides gentle midline compression, reduces discomfort, improves proprioception
  • Worn during active tasks, not 24/7
  • Avoid over-reliance — can inhibit intrinsic core training
  • Consider in early postpartum (weeks 0–6), after CS, or severe DRA
• Kinesio taping (KT Tape): Strips applied horizontally across midline with 25% tension
  • May reduce pain and provide tactile feedback for posture
  • Evidence limited but low-risk adjunct
• Compression shorts / high-waisted leggings: Comfortable option for daily wear

CS Scar Management (if applicable)

• From 6–8 weeks postpartum (once healed): scar desensitization, mobilization
• Prevents scar tethering which restricts fascial mobility and abdominal mechanics

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PHASE 2 — DEEP CORE RE-EDUCATION (Weeks 4–12)

Exercise 1: Diaphragmatic Breathing with Pelvic Floor Coordination

• Supine, knees bent, hands on lower ribs
• Inhale: Ribs expand laterally and anteriorly; lower abdomen rises gently; pelvic floor descends naturally (do not force)
• Exhale: Ribs drop; lower abdomen draws gently inward; pelvic floor lifts naturally
• Key: pelvic floor and TrA response is passive and automatic with correct breathing
• 10 breath cycles, 3× daily
• Progress: seated, standing, then during movement

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Exercise 2: Abdominal Drawing-In Maneuver (ADIM)

• Supine hook-lying
• Gently draw lower abdomen inward and upward (navel toward spine)
• Do NOT: flatten the entire lumbar spine, hold the breath, or activate all abdominals together
• Feel for gentle tensioning of lower abdominal wall (not a hard brace)
• Hold: 8–10 seconds; Repetitions: 10; Sets: 3–4; Frequency: 2–3×/day

1. Hook-lying → 4-point kneeling → sitting → standing
2. Add limb movement (heel slides) while maintaining activation

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Exercise 3: Pelvic Floor Contractions (Kegels)

• Identify pelvic floor: imagine stopping flow of urine AND stopping passing wind simultaneously
• Contract upward and inward (elevator going up)
• Hold: 8–10 seconds; Relax fully 4–8 seconds between
• Repetitions: 8–12; Sets: 3; Frequency: 3×/day

• Quick flick contractions
• 10 quick contractions; Sets: 3; Frequency: 3×/day

• Exhale + pelvic floor lift + TrA gentle activation — the three happen simultaneously
• Teaches proper IAP management for all activities

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Exercise 4: 4-Point Kneeling Multifidus / Arm Lift

• 4-point kneeling (wrists under shoulders, knees under hips)
• Neutral spine (not arched or flattened)
• Activate ADIM; lift one arm to shoulder height only
• Maintain spine position; do not rotate
• Hold: 5–8 seconds; 8–10 reps per side; 2–3 sets

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PHASE 3 — FUNCTIONAL CORE LOADING (Weeks 8–16)

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Exercise 5: Dead Bug

• Activate TrA (ADIM) and pelvic floor
• Exhale: slowly lower right arm overhead toward floor + simultaneously extend left leg toward floor (heel 5 cm above floor)
• Inhale: return to start
• Alternate sides
• Key: lumbar spine must NOT lift off floor; NO doming; NO breath-holding
• Progression: add resistance band on arms or ankle weight on leg

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Exercise 6: Bird-Dog

• Activate TrA; exhale and extend right arm to shoulder height + left leg to hip height simultaneously
• Do not rotate hips; maintain completely level pelvis
• Hold 5–8 seconds; return slowly
• Alternate sides

1. Arm only → Leg only → Combined
2. Add theraband resistance on arm
3. Add ankle weight
4. Perform on unstable surface (BOSU)

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Exercise 7: Glute Bridge

• Activate TrA + pelvic floor; exhale and push through heels
• Lift hips until shoulder-hip-knee alignment achieved
• Hold 2–3 seconds; lower slowly while maintaining TrA
• Do NOT hyperextend lumbar spine at top
• Progress: march in bridge (alternate leg lifts), single-leg bridge, bridge with resistance band around knees

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Exercise 8: Heel Slides

• Exhale; slide one heel slowly along the floor until leg fully extended (heel hovers 2 cm above floor)
• Inhale; slowly return
• Maintain lumbar neutral throughout
• Progress to bilateral alternating, then double leg slides

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Exercise 9: Side-Lying Hip Abduction / Clamshell

• Maintain stacked pelvis; open top knee upward like a clamshell
• Do NOT allow pelvis to roll backward
• Resistance band around knees to increase load

• Straight top leg lifts to 30°; hold 2 seconds; lower
• Resistance band around ankles

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Exercise 10: Modified Kneeling Plank

• Maintain neutral spine (no sagging hips, no elevated hips)
• Activate TrA; breathe normally throughout (no breath-holding)
• Watch for: doming, hips sagging, lumbar overextension
• Progress to: full plank on toes (only if no doming observed)

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Exercise 11: Pallof Press (Anti-Rotation Press)

• Hold band/cable at chest; activate TrA
• Exhale: press arms straight forward; hold 3 seconds; maintain square pelvis and shoulders
• Inhale: return to chest
• The band pulls you rotationally — resist that rotation

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PHASE 4 — ADVANCED LOADING & RETURN TO SPORT (Weeks 16+)

Clearance Criteria Before Phase 4

• IRD within acceptable range (or stable with good tension)
• No doming with plank, bird-dog, dead bug
• ASLR test improved / resolved
• Pelvic floor: no SUI with running or jumping
• Good breathing mechanics under moderate load

Advanced Exercises

• Bilateral farmer's carry (dumbbells at sides)
• Suitcase carry (unilateral — increases anti-lateral flexion demand)
• Overhead carry
• Progress weight weekly

• Romanian deadlift → Barbell deadlift
• Teach: inhale + brace on descent; exhale on ascent
• Correct bracing (360° abdominal brace, not just drawing-in) appropriate in this phase for heavy loads

• Goblet squat → Front squat → Back squat
• Monitor for rib flare and lumbar overextension

• Only after: no pelvic floor leakage, adequate hip strength, single-leg stability
• Walk-run intervals progressively increasing run time

• Assess for pelvic floor leakage first
• Begin with double-leg low hops → progress to HIIT, box jumps, sport-specific

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7.2 Surgical Management

Indications for Surgical Referral

• IRD persistently > 3–4 cm with significant dysfunction after 6+ months of consistent physiotherapy
• Associated umbilical or epigastric hernia
• Absent linea alba tension non-responsive to conservative treatment
• Severe functional limitation (cannot perform ADLs)
• Patient preference for cosmetic correction with functional failure
• Severe abdominal ptosis not correctable conservatively

Surgical Procedures (Detailed)

Post-Surgical Physiotherapy

• Weeks 0–4: Education, breathing, log-roll technique, gentle TrA activation, walking
• Weeks 4–8: Progressive ADIM, pelvic floor, scar mobilization (from 6 weeks)
• Weeks 8–16: Functional core loading (Phase 2–3 program)
• Weeks 16+: Return to sport protocol

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PART 8: ROLE OF CORE EXERCISES IN DRA — IN DEPTH

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8.1 Why Core Exercise is the Foundation of DRA Treatment

Mechanism 1: TrA Activation Narrows IRD

• Improved neuromuscular recruitment patterns
• Increased resting TrA tone over time
• Better anticipatory pre-activation before loading tasks

Mechanism 2: Restoration of Linea Alba Tension

• Collagen fiber remodeling (mechanotransduction)
• Improved cross-linking
• Restoration of the three-dimensional collagen weave architecture

Mechanism 3: Lumbopelvic Stability Restoration

• Pre-activation before limb movements is restored
• Passive structures (lumbar discs, ligaments) are protected from excessive load
• LBP and PGP resolve
• Functional tasks become less painful and easier

Mechanism 4: IAP Regulation

• Excessive spikes with coughing, lifting, exercise
• Pelvic floor overload
• Doming with effort

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8.2 Core Exercise Safety Principles in DRA

Principle 1: The No-Doming Rule

• IAP exceeds linea alba resistance
• Abdominal contents herniate forward through the gap
• The linea alba is loaded beyond its capacity
• Progressive tissue damage may occur

Principle 2: Exhale on Effort

• Prevents Valsalva maneuver
• Coordinates pelvic floor contraction with abdominal effort
• Reduces IAP spike
• Protects linea alba

Principle 3: Tension Over Width

Principle 4: Progressive Overload

• Lever arm length (bent knee → straight leg)
• External resistance (no weight → dumbbells → barbell)
• Instability (stable → unstable surface)
• Speed (slow → functional speed)

Principle 5: Pelvic Floor Co-Treatment

• Leaves IAP dysregulation unresolved
• Fails to address SUI/prolapse
• Undermines abdominal wall rehabilitation

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8.3 Exercises to AVOID in DRA (and Why)

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8.4 Complete Evidence-Based Core Exercise Program

STAGE 1: Weeks 1–6

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STAGE 2: Weeks 4–12

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STAGE 3: Weeks 8–16

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STAGE 4: Weeks 16+

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8.5 Scientific Evidence Summary

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PART 9: SPECIAL POPULATIONS

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9.1 Postpartum DRA (Most Common Presentation)

Postpartum Staging

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9.2 Male DRA

• Typically presents as upper abdominal bulge in overweight, middle-aged men (Bailey & Love, p.1079)
• Mechanism: chronic IAP elevation from obesity + poor abdominal wall tone
• Often associated with umbilical or epigastric hernia
• Management same principles; weight loss is an additional priority
• Higher surgical intervention rate (less hormonal resolution, often larger gap)

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9.3 Neonatal / Infant DRA

• Normal variant at birth — rectus muscles have not yet fused
• Resolves spontaneously in > 95% of cases by 12 months
• No treatment required unless persists beyond 2 years
• Reassure parents

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9.4 DRA with Connective Tissue Disorder (Ehlers-Danlos, Marfan)

• More severe, recurrent, and refractory DRA
• Conservative management aims to maximize muscle support of weakened fascia
• Surgical repair results less durable — inform patient
• Multidisciplinary management with rheumatology

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PART 10: PROGNOSIS & OUTCOMES

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SUMMARY REFERENCE TABLE