Diastasis recti

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Diastasis recti
Other namesAbdominal separation
Hernie ligne blanche.JPG
Diastasis recti in an infant
Specialty Pediatrics
Diastasis recti. 72-year-old man, epigastric protrusion when raising the head. Diastasis recti, old man.jpg
Diastasis recti. 72-year-old man, epigastric protrusion when raising the head.

Diastasis recti, or rectus abdominis diastasis, is an increased gap between the right and left rectus abdominis muscles. [1] The increased distance between the muscles is created by the stretching of the linea alba, a connective collagen sheath created by the aponeurosis insertions of the transverse abdominis, internal oblique, and external oblique. [2] This condition has no associated morbidity or mortality. Physical therapy is often required to repair this separation and surgery is an option for more severe cases. Standard exercise rarely results in complete healing of the separated muscles. [3]

Contents

Diastasis of the rectus abdominis muscle most frequently occurs in newborns and pregnant women; however, it may occur in any adult woman or man. In the newborn, the rectus abdominis is not fully developed and may not be sealed together at midline. Diastasis recti is more common in premature newborns. In pregnant or postpartum women, the condition is caused by the stretching of the rectus abdominis by the growing uterus. It is more common in multiparous women (women who have had multiple pregnancies) owing to repeated episodes of stretching. When the defect occurs during pregnancy, the uterus can sometimes be seen bulging through the abdominal wall beneath the skin. Non-pregnant women are more susceptible to develop diastasis recti when over the age of 35 or with high birth weight of child, multiple birth pregnancy, or multiple pregnancies. Additional causes can be attributed to excessive abdominal exercises after the first trimester of pregnancy. [4]

Strength training of all the core muscles, including the abdominis recti muscle, may reduce the size of the gap in pregnant or postpartum women. Crunches may increase the diastasis recti separation. All corrective exercises should be in the form of pulling in the abdominal muscles rather than pushing them outwards. In extreme cases diastasis recti is corrected with a cosmetic surgery procedure known as an abdominoplasty by creating a plication, or folding, of the linea alba and suturing it together, which results in a tighter abdominal wall.

Presentation

A diastasis recti may appear as a ridge running down the midline of the abdomen, anywhere from the xiphoid process to the umbilicus. It becomes more prominent with straining and may disappear when the abdominal muscles are relaxed. The medial borders of the right and left halves of the muscle may be palpated during contraction of the rectus abdominis. [5] The condition can be diagnosed by physical exam, and must be differentiated from an epigastric hernia or incisional hernia, if the patient has had abdominal surgery. [3] Hernias may be ruled out using ultrasound. [6]

In infants, they typically result from a minor defect of the linea alba between the rectus abdominis muscles. This allows tissue from inside the abdomen to herniate anteriorly. On infants, this may manifest as an apparent 'bubble' under the skin of the belly between the umbilicus and xiphisternum (bottom of the breastbone). [7]

Examination is performed with the subject lying on the back, knees bent at 90° with feet flat, head slightly lifted placing chin on chest. With muscles tense, the examiner then places fingers in the ridge that is presented. Measurement of the width of separation is determined by the number of fingertips that can fit within the space between the left and right rectus abdominis muscles. Separation consisting of a width of 2 fingertips (approximately 1 1/2 centimeters) or more is the determining factor for diagnosing diastasis recti. [8]

Diagnosis

Abdominal ultrasound of diastasis recti, being the distance between the green crosses. Ultrasonography of diastasis recti - Annotated.jpg
Abdominal ultrasound of diastasis recti, being the distance between the green crosses.

Diastasis recti can be diagnosed by physical examination, which may include measuring the distance between the rectus abdominis muscles at rest and during contraction at several levels along the linea alba. [9] Diastasis recti is defined as a gap of about 2.7 cm or greater between the two sides of the rectus abdominis muscle. [1] Abdominal ultrasonography provides objective evidence for the diagnosis, and also confirms that the bulge is not a hernia. [9] An abdominal CT scan may also visualise diastasis recti. [9]

Treatment

Strength training

A 2014 systematic review found that the width of the gap in diastasis recti may be reduced by exercising during and after pregnancy. [1]

A 2018 review mentions other techniques in addition to strengthening exercises: postural training; education and training for proper lifting mechanisms; manual therapy (which includes soft tissue mobilization); myofascial release; Noble technique (i.e., manual approximation of abdominal muscles during partial sit-up); and abdominal bracing and taping. Other techniques to strengthen abdominal muscles are using Pilates and functional training. [12]

Surgery

In extreme cases, diastasis recti is corrected with a cosmetic surgery procedure known as an abdominoplasty by creating a plication or folding of the linea alba and suturing together. This creates a tighter abdominal wall. There are two surgical methods: one more common through plication of the anterior rectus sheath; and the other through hernia repair, considering suture closure of the hernia sac combined with mesh reinforcement. Two studies showed few post-operative complications. [13]

Related Research Articles

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The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubic symphysis. In females, the pubic symphysis is attached to the suspensory ligament of the clitoris. In most adults, it can be moved roughly 2 mm and with 1 degree rotation. This increases for women at the time of childbirth.

<span class="mw-page-title-main">Abdominoplasty</span> Surgical procedure to make the abdomen thinner and firmer

Abdominoplasty or "tummy tuck" is a cosmetic surgery procedure used to make the abdomen thinner and more firm. The surgery involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall. This type of surgery is usually sought by patients with loose or sagging tissues, that develop after pregnancy or major weight loss.

<span class="mw-page-title-main">Linea alba (abdomen)</span> Fibrous structure of the abdomen

The linea alba is a strong fibrous midline structure of the anterior abdominal wall situated between the two recti abdominis muscles. The umbilicus (navel) is a defect in the linea alba through which foetal umbilical vessels pass before birth. The linea alba is formed by the union of aponeuroses that collectively make up the rectus sheath. The linea alba attaches to the xiphoid process superiorly, and to the pubic symphysis inferiorly. It is narrow inferiorly where the two recti abdominis muscles are in contact with each other posterior to it, and broadens superior-ward from just inferior to the umbilicus.

<span class="mw-page-title-main">Rectus abdominis muscle</span> Paired straight muscle

The rectus abdominis muscle, also known as the "abdominal muscle" or simply the "abs", is a pair of segmented skeletal muscle on the ventral aspect of a person's abdomen. The paired muscle is separated at the midline by a band of dense connective tissue called the linea alba, and the connective tissue defining each lateral margin of the rectus abdominus is the linea semilunaris. The muscle extends from the pubic symphysis, pubic crest and pubic tubercle inferiorly, to the xiphoid process and costal cartilages of the 5th–7th ribs superiorly.

<span class="mw-page-title-main">Transverse abdominal muscle</span> Muscle of the abdominal area

The transverse abdominal muscle (TVA), also known as the transverse abdominis, transversalis muscle and transversus abdominis muscle, is a muscle layer of the anterior and lateral abdominal wall, deep to the internal oblique muscle. It is thought by most fitness instructors to be a significant component of the core.

<span class="mw-page-title-main">Umbilical hernia</span> Medical condition

An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The bulge can often be pressed back through the hole in the abdominal wall, and may "pop out" when coughing or otherwise acting to increase intra-abdominal pressure. Treatment is surgical, and surgery may be performed for cosmetic as well as health-related reasons.

<span class="mw-page-title-main">Abdomen</span> Part of the body between the chest and pelvis

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In human anatomy, the inferior epigastric artery is an artery that arises from the external iliac artery. It is accompanied by the inferior epigastric vein; inferiorly, these two inferior epigastric vessels together travel within the lateral umbilical fold The inferior epigastric artery then traverses the arcuate line of rectus sheath to enter the rectus sheath, then anastomoses with the superior epigastric artery within the rectus sheath.

<span class="mw-page-title-main">Superior epigastric artery</span> Blood vessel

In human anatomy, the superior epigastric artery is a terminal branch of the internal thoracic artery that provides arterial supply to the abdominal wall, and upper rectus abdominis muscle. It enters the rectus sheath to descend upon the inner surface of the rectus abdominis muscle. It ends by anastomosing with the inferior epigastric artery.

<span class="mw-page-title-main">Epigastric hernia</span> Medical condition

An epigastric hernia is a type of hernia that causes fat to push through a weakened area in the walls of the abdomen. It may develop in the epigastrium. Epigastric hernias are more common in adults and usually appear above the umbilical region of the abdomen. It is a common condition that is usually asymptomatic although sometimes their unusual clinical presentation can present a diagnostic dilemma for the clinician. Unlike the benign diastasis recti, epigastric hernia may trap fat and other tissues inside the opening of the hernia, causing pain and tissue damage. It is usually present at birth and may appear and disappear only when the patient is doing an activity that creates abdominal pressure, pushing to have bowel movements, or crying.

<span class="mw-page-title-main">Arcuate line of rectus sheath</span> Line of demarcation in the human abdomen

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The linea semilunaris is described by Adriaan van den Spiegel described the Linea Semilunaris as the line forming and marking the transition from muscle to aponeurosis in the transversus abdominis muscle of the abdomen. It needs to be distinguished from the lateral border of the rectus abdominis muscle sheath which is often wrongly described as semilunar line. The lateral border of the rectus sheath is part of the recently described EIT ambivium to more precisely describe this important part of the anterior abdominal wall. The EIT ambivium is formed by the Musculus Obliquus Externus (MOE), the Musculus Obliquus Internus (MOI) and the Musculus Transversus Abdominis (TA). Understanding the interrelationship between the lateral muscles and the medial compartment is of paramount importance for surgeons to understand the surgical anatomy.

<span class="mw-page-title-main">Symphysis pubis dysfunction</span> Medical condition

Symphysis pubis dysfunction (SPD), commonly known as pubic symphysis dysfunction or lightning crotch, is a condition that causes excessive movement of the pubic symphysis, either anterior or lateral, as well as associated pain, possibly because of a misalignment of the pelvis. Most commonly associated with pregnancy and childbirth, it is diagnosed in approximately 1 in 300 pregnancies, although some estimates of incidence are as high as 1 in 50.

<span class="mw-page-title-main">Tendinous intersection</span> Three fibrous bands crossing the rectus abdominis muscle

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<span class="mw-page-title-main">Pubic symphysis diastasis</span> Medical condition

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In surgery, a surgical incision is a cut made through the skin and soft tissue to facilitate an operation or procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as small and unobtrusive as possible to facilitate safe and timely operating conditions.

Signs and symptoms of pregnancy are common, benign conditions that result from the changes to the body that occur during pregnancy. Signs and symptoms of pregnancy typically change as pregnancy progresses, although several symptoms may be present throughout. Depending on severity, common symptoms in pregnancy can develop into complications. Pregnancy symptoms may be categorized based on trimester as well as region of the body affected.

References

  1. 1 2 3 Benjamin, D.R.; Van de Water, A.T.M; Peiris, C.L. (March 2014). "Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review". Physiotherapy. 100 (1): 1–8. doi: 10.1016/j.physio.2013.08.005 . PMID   24268942.
  2. ↑ Brauman, Daniel (November 2008). "Diastasis Recti: Clinical Anatomy". Plastic and Reconstructive Surgery. 122 (5): 1564–1569. doi:10.1097/prs.0b013e3181882493. PMID   18971741. S2CID   26635878.
  3. 1 2 Norton, Jeffrey A. (2003). Essential practice of surgery: basic science and clinical evidence . Berlin: Springer. pp.  350. ISBN   0-387-95510-0.
  4. ↑ Harms, M.D., Roger W. "Why do abdominal muscles sometimes separate during pregnancy?".
  5. ↑ "University of Pennsylvania Health System | Penn Medicine". www.pennmedicine.org.
  6. ↑ Lassandro, Francesco; Iasiello, Francesca; Pizza, Nunzia Luisa; Valente, Tullio; Stefano, Maria Luisa; Grassi, Roberto; Muto, Roberto; di Santo Stefano, Mangoni (2011). "Abdominal hernias: Radiological features". World Journal of Gastrointestinal Endoscopy. 3 (6): 110–117. doi: 10.4253/wjge.v3.i6.110 . PMC   3158902 . PMID   21860678.
  7. ↑ "Diastasis recti: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2020-10-29.
  8. 1 2 Engelhardt, Laura (1988). Comparison of two abdominal exercises on the reduction of the diastasis recti abdominis of postpartum women (Thesis). OCLC   60754579. ProQuest   303651963.
  9. 1 2 3 Maurice Nahabedian, David C Brooks. "Rectus abdominis diastasis". UpToDate . Retrieved 2018-01-26. Topic 100494 Version 5.0
  10. ↑ "How to fix diastasis recti years later". www.toningforwomen.com. 19 July 2022. Retrieved 2022-11-02.
  11. ↑ "Diastasis recti: MedlinePlus Medical Encyclopedia". medlineplus.gov.
  12. ↑ Michalska, Agata; Rokita, Wojciech; Wolder, Daniel; Pogorzelska, Justyna; Kaczmarczyk, Krzysztof (2018). "Diastasis recti abdominis — a review of treatment methods". Ginekologia Polska. 89 (2): 97–101. doi: 10.5603/GP.a2018.0016 . PMID   29512814.
  13. ↑ Mommers, Elwin H. H.; Ponten, Jeroen E. H.; Al Omar, Aminah K.; de Vries Reilingh, Tammo S.; Bouvy, Nicole D.; Nienhuijs, Simon W. (December 2017). "The general surgeon's perspective of rectus diastasis. A systematic review of treatment options". Surgical Endoscopy. 31 (12): 4934–4949. doi:10.1007/s00464-017-5607-9. PMC   5715079 . PMID   28597282.
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