Mind the Gap Part II: Improving the Look and Function of the Mommy Tummy (Diastasis Recti)


Welcome to part two of Mind the Gap: Improving the look of Mommy Tummy. For Part one and more background, check out Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I.

Joanna Hess, PT, DPT, PRC, WCS  (practices at our down town office)

So, about that flat tummy. I want it.

Our bodies can be amazingly resilient and are constantly adapting if given the opportunity. Think about an ankle sprain—in order for the overstretched ligaments to heal, the ankle needs be in a position without excessive strain. Conversely, limiting motion over a long period decreases the body’s signal to rebuild the area. We need the Goldilocks treatment—just enough movement and challenge without too much strain. We can use these same principles for understanding the self-resolving diastasis recti. The strained linea alba and loose skin associated with diastasis, like so many other parts of the body, will produce fibroblasts to improve collagen and elastin (the building blocks of skin and other connective tissue), if it is given appropriate mechanical load.

Here are some tips for dealing with diastasis:

1. Patience. 100% of women have a diastasis recti (DRA) at the end of the third trimester. Postpartum, 52-60% of women have a diastasis at 6 weeks, 39-45% at 6 months (1, 7) with effects on abdominal strength and endurance (10), and 33% at 12 months. Most improvement happen before 6-12 months, but can continue to 24 months without specific intervention (10,11).

2. Nutrition. This is out of my league, but understandably important, particularly early post-postpartum. Consult your favorite integrative nutritionist. But for starters, bone broth and vitamin C are widely touted to help collagen production. Also, make sure to stay hydrated. Don’t waste your time on the creams. The body needs internal signaling and cellular level building blocks to increase collagen production.

3. Dance, laugh, live. Regular and progressive 3D movement that requires the abdominal system to stabilize, to lengthen, to contract, to work is an easy way to load the system. This translates into activities like laughing really hard, reaching up for things on the top shelf, lifting a child, twisting to grab a cookie, or walking really fast with arms swinging. With some exceptions for pain and loss of the ability to do everyday tasks, limit abdominal bracing techniques such as taping, belly binding, and second skin Spanx. These push pressure elsewhere in the system and decrease the signal for the body to rebuild. We want as much motion that the body can handle without losing its stability.

4. Managing abdominal pressure. The abdominal canister—the multifidus muscles of the back, the respiratory diaphragm at the top, the pelvic floor on the bottom, and abdominals in the front—contains most of the body’s organs and manages fluctuating intra-abdominal pressures. Adopting better posture and movement patterns help manage intra-abdominal pressures taking off excess strain and help resolve DRA.

5. Breathe and wiggle the ribs. Sigh and drop those ribs. A rib flare (thank you baby, and organs that relocated into the rib cage real estate) adds a strain on the linea alba. An easy way to safely challenge the system may be as simple as raising your arms over your head while keeping your ribs down. Or spend some time doing diaphragmatic breathing adding gentle twisting on the exhale.

6. Battle of the ab exercises: Transverse abdominis vs. Rectus abdominis (RA). Women who do specific transverse abdominis exercises are less likely to have a DRA during pregnancy and postpartum as compared to women who have a general exercise program (6, 12, 13). These exercises are focused on a phrase that I like to use, coined by the Institute of Physical Art, “keeping the baby in the bucket”. Cautiously get excited about a very small study that found women who exercised during pregnancy (pelvic tilts and transversus abdominis) had a lower rate (12.5%) of significant postpartum DRA vs non-exercisers (90%) despite DRA during pregnancy (13). A systematic review notes how little we know about exercise for prevention of DRA. A prenatal abdominal exercise program will prevent 1 in 3 women from developing DRA, but unclear as to which exercises should be included (14). Almost 90% of physical therapists use transverse abdominis and pelvic floor training with their patients, and up to 63% of physical therapists use the Noble method which combines the physical approximation of the muscle bellies while doing an abdominal crunch (3).

What happens with a transverse abdominis contraction? The transverse abdominis (TrA) is typically cued with the drawing in of the abdomen keeping the upper abdominal soft. You can feel the difference in the contraction just inside the front of the inside hip—trampoline tension for TrA and hard bulge for the obliques/RA. For most people contracting the TrA will increase the space between the abs (1, 8, 15, 16) while linea alba distortion decreases (8). The decrease in linea alba distortion corresponds with an increase of tension of the linea alba. Based on a small research sample and case series, progressive pelvic floor and TrA exercises decrease the space between the abs (13, 17), possibly by vertically aligning the rectus abdominis muscles, increasing mechanical strain and increasing fibroblast activity for collagen synthesis.

What happens with rectus abdominis contraction? The abdominal crunch activates the rectus abdominis muscle. Usually when people with DRA do a crunch, the space between the abs decreases (1, 8, 15, 16), but the linea alba distortion increases as the tension is decreased (8). The RA muscle length increases during pregnancy and immediately postpartum, but not enough to decrease the ability for the muscle to generate forces vertically (18). As pregnancy and DRA progresses, the change from vertical orientation to diagonal insertion of the RA muscle fibers likely decreases the ability to generate forces effectively. Perhaps, the decrease in force transfer at the linea alba with RA contraction is more related to the orientation of the muscle fibers instead of the movement of abdominal crunch itself.

The winner is transverse abdominis! Based on what we know so far, the exercises that include recruitment of the TrA are most effective at improving the force tension and closing the DRA over time. Passive external supports can be used as part of a progression if the TrA is unable to activate on its own. The TrA needs to be trained to turn on and off which allows for the intermittent tension and internal signaling required for the linea alba and abdominals to adapt to a new position and for collagen synthesis. There are many ways to do this, but here’s a suggested progression:

1. Standing arms overhead with ribs down and diaphragmatic breathing (Irene, our personal trainer, shows a variation lying down)

2. Noble technique with diaphragmatic breathing

3. Sahrmann transverse abdominis progression

4. TrA brace with quadruped alternating arm/leg lift

5. TrA with squat to single leg squat with diaphragmatic breathing

6. TrA with Turkish get-up

7. See a specialized physical therapist. Postpartum pelvic floor therapy is the norm wellness program for most of Western Europe. Like I mentioned before, the variability of why some people do better than others is not well understood. However, a specialized physical therapist will assess how you uniquely go through everyday life and can suggest ways to improve the efficiency of your abdominal pressure system, to give more input in places that are sleepy, and to quiet the overloaded parts. We teach, monitor and appropriately progress your exercise program and functional integration to appropriately challenge without overloading deficient muscles. On a blog, it’s easy to talk about the transverse abdominis, but actually recruiting and integrating this muscle without overloading others, often requires extensive cues, sometimes manual techniques, and adjustments at other parts of the body. 59% of physical therapist use some type of manual technique to treat DRA including 21% using visceral mobilization. A case series demonstrated that the mobilization of the jejunoileum can help to resolve DRA (19). Postural education, exercise progression, abdominal pressure management, and visceral mobilization are part of our regular program for diastasis recti at Beyond Basics Physical Therapy.

We know that the body and linea alba are highly adaptable. The research is unclear regarding the risk factors of DRA, the important measures for DRA regarding function and resolution, and why the TrA seems so important for healing DRA even though its contraction temporarily widens the gap. We do not know how to best nudge the body to produce new collagen for DRA, but if it is anything like the rest of the body, it responds well to intermittent contractile loads and responds poorly to static underloading or overloading. In the meantime, we can hope to see America’s next top model with a real-life mummy tummy that shifts our cultural ideas of beauty and health.


Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

Joanna Hess is a treating therapist at our downtown location

Joanna Lee Hess


1. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1; 20(1):200-5.

2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48.

3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women’s health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36

4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8

5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22.

6. Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and
urodynamics. 2017 Mar 1; 36(3):716-21.

7. 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.

8. 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.

9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45.

10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. journal of orthopaedic & sports physical therapy. 2011 July.

11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21.

12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6

13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6.

14. 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.

15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8.

16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91.

17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73.

18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7.

19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.


It’s all connected: How pelvic floor dysfunction can contribute to hip pain

Yoga 2

Kaitlyn Parrotte, PT, DPT, OCS, CFMT (practices at our midtown office)

Hip pain can have a significant burden on function and quality of life. While there are many causes, prevailing research shows that hip pain is common in both athletic and older populations (1,2). In athletes, groin pain accounts for 10% of all visits to sports medicine centers, and groin injuries account for up to 6% of all athletic injuries (1). In older adults, a diagnosis like osteoarthritis is common, and is ranked as the eleventh highest contributor of global disability (2). While research often focuses on specific populations of people or diagnoses, when put together, it reveals that general hip pain is a common problem affecting a significant portion of the general population. There are many diagnoses that exist to describe hip pain, with the ultimate goal to develop the most effective course of treatment. Traditionally, when someone with hip pain visits a doctor, a physical examination will be performed, which includes assessing for tenderness, swelling, or redness, and determining the range of motion at the hip joint. The doctor may also recommend imaging, such as an x-ray or MRI, as well as lab tests (3). While this can provide a physician with valuable information, such examinations have the risk of missing causes of pain from nearby structures, such as the pelvic floor.


The pelvic floor muscles are three layers of muscles that attach to the lower aspect of each half of the pelvis from side-to-side and from the pubic bone to the tailbone, front-to-back. These muscles support the pelvic organs, as well as contribute to trunk stability, and play a significant role in bowel and bladder control and efficiency, as well as sexual function (4). The muscles that make up the deepest of the pelvic muscles, include the levator ani and coccygeus, as well as the obturator internus on the sides (5). The pelvic floor is interconnected to many key structures in the body, and dysfunction here can affect seemingly unrelated parts of the body. Below are two cases of unresolving hip pain, where assessment and treatment of the pelvic floor helped to promote a return to recreational activities.



A 32-year-old male professional cyclist came to physical therapy with complaints of pain in his right hip and groin, mainly with prolonged sitting and cycling. This began soon after he suffered severe bruising on his right hip from a fall, with a tear of two hip muscles (tensor fascia lata on the front and gluteus medius on the side). Prior to this, he had a history of multiple leg injuries due to cycling, but had never complained of any pelvic floor issues. Upon examination, decreased hip range of motion was also discovered. Initially, he received ten sessions of “standard physical therapy,” which included stretching, joint mobilization, soft tissue release, dry needling, and exercise.

However, after only minimal improvement, he was referred to a pelvic floor specialist for further evaluation where increased muscle tone and tenderness in multiple pelvic floor muscles (both obturator internus muscles and both iliococcygeus muscles) were discovered. Also, weakness of a pelvic floor contraction was also noted (6). Based on response to treatment, his hip pain decreased significantly from his current treatment of pelvic floor dysfunction, though it was completely missed in the initial testing.

But how does pelvic floor dysfunction contribute to hip pain? The correct treatment was missed because this connection was missed. Consider the anatomy and mechanics of the hip and pelvis. The gentleman described above is a professional cyclist, which means that whenever he is on his bicycle, he must flex (bend) his hip up to 90 degrees. More hip motion does not tend to occur because it would cause the pelvis to become unstable on the small seat (7). When the hip is bent, the femoral head (ball of the ball-and-socket joint) must flex (bend up), abduct (move to the side), and rotate in towards the groin (8). As the pedal is pushed downward, the hip moves into an extension (straightening) position. Although the hip never reaches a fully straightened position when cycling because he is seated, the hip moves through between 40 and 43 degrees of total motion with each cycle of the pedal (7). So, when the hip is moving into that straightened position, that femoral head must extend (move back), adduct (move sideways toward the groin), and rotate out away from the groin. While the movements of ball of the hip are small, as they are occurring with the confines of the socket in the pelvis, it is important to remember what muscles are in close proximity (8).

Besides the extensive list of hip flexors and gluteus muscles, there are several muscles that sit on the inner side of each hip and the bottom layer of the pelvis – the muscles of the pelvic floor. The two muscles that are of the most interest in this case are the obturator internus and the iliococcygeus muscles, as tightness and tenderness were found in each pair. The obturator internus muscle contributes to the walls of the pelvic floor, on each side of the pelvis. and sits on the inner side of the hip joint. The iliococcygeus muscle attaches on one end into the tendinous arch of the obturator fascia, so there is only dense connective tissue joining this muscle and the obturator internus (5).

When the hip is in a bent position the obturator internus muscle abducts the hip, or moves it to the side, away from midline; however, when the hip is extended (straightened) this muscle rotates the hip outward. For the iliococcygeus muscle, its role is one of support for the pelvic contents and lifting for the pelvic floor (5). Considering all these factors, it can be theorized that when the hip is in a bent position at the top of the pedaling cycle the obturator internus is activated through the abduction (sideways) motion of the ball of the hip, and continues to be activated as the hip straightens since the ball is rotating outward. Furthermore, because the iliococcygeus muscle is attached to the obturator internus muscle through a dense strip of connective tissue, it must work harder to help support this obturator muscle throughout the cycling activity. Thus, these muscles have become overused and shortened with regular and intense cycling required of a professional, who likely had some abnormal muscle activation or movement strategies prior to his pain due to previous injuries.

With the specially trained pelvic floor physical therapist, the pelvic floor connective tissue was mobilized internally over two treatment sessions, in addition to the cyclist performing hip stabilizing exercises. After the first session, there was an immediate and significant improvement in hip range of muscle and pelvic floor muscle contraction; furthermore, sitting pain was resolved. After the second session (7 days later) this gentleman was discharged from PT as he was pain free in sitting and cycling. In a follow up call one month after discharge, he was still pain free without altering training (6). This dramatic change occurred because the release of connective tissue in the pelvic floor decreased tension and trigger points in the obturator internus and iliococcygeus muscles. Thus, his hip range of motion and pain were normalized, and he was able to return to competitive cycling without restrictions.

Case 2: A RUNNER

A 45-year-old female was referred to physical therapy by her gynecologist with an initial diagnosis of left hamstring strain, toward the top of the thigh, related to distance running. This woman was an experienced marathon runner, who ran an average of 30-40 miles per week. She presented to her first PT appointment with pain in her left sit bone, with diffuse aching radiating into her left buttock and pubic bone; she stated her pain began about 4 months prior to her first PT session. The mechanism of injury was “pulling a muscle” while trying to avoid falling on a trail run. At that time, she immediately felt pain near her sit bone, but was able to complete her run. Eventually, as her symptoms progressed, she stopped running, and was only able to tolerate about 15 minutes of sitting. By her fourth PT visit, her pain had decreased, but continued mildly with sitting and shifted into her left pubic bone. She also reported a deep ache that could not be touched from the outside. She was referred to a pelvic floor specialist for further evaluation; upon internal assessment of the pelvic floor, significant tenderness and reproduction of the “deep ache” was found in her left levator ani and obturator internus muscles, as well as increased muscle tone. Furthermore, contraction of these muscles was weak, and she presented with poor relaxation of the same muscles. (9).

The hamstring muscles attach to the sit bone, and in running help to extend the hip and control the knee (10). Due to the location of this woman’s complaints, initial treatments focused on pain management, such as sitting on a wedge or donut to relieve pressure on her sit bone, as well as core strengthening exercises like the plank, and gluteus and hamstring strengthening exercises. Since the patient reported relief of sit bone pain, except with prolonged sitting by her fourth visit, it was logical to directly address the hamstring and gluteus muscles; however, these are not the only muscles in the area of the hip (9).

When this woman was assessed by a pelvic floor specialist, weakness, tightness, and tenderness were discovered in her obturator internus and levator ani muscles on the side of her pain (9). As discussed in the first case, the obturator internus muscle makes up part of the wall of the pelvis and sits just inside of the pelvis, past the hip joint (5). With running, an efficient hip will move between 50 degrees flexion (bending up) and 10 degrees of extension (straightening back) (10). Thus, when the hip is flexing, the obturator internus is likely assisting with abduction of the ball of the hip joint, and when the hip is extending the obturator internus muscle is likely active in outward rotation of the ball (5,8). The levator ani muscles attach from the pubic bone in the front to the back portion of the pelvis, and play an important role in stabilizing the pelvis and the pelvic contents (5). Considering the mechanics of running, the obturator internus and levator ani muscles were likely working hard to promote a good running pattern, and when she tripped on a run, these muscles were overexerted. Then they continued to overwork to compensate for the pain and weakness demonstrated by her hamstring muscles.

In addition to exercises for hamstring and gluteal muscles, internal release of the left levator ani and obturator internus muscles was performed, as well as gentle isometric contractions for strengthening and lengthening of pelvic floor for relaxation. After 7 additional sessions over a 2-month period, this woman’s pain had decreased greatly, she was able to tolerate sitting for more than two hours, she was able to hop on her left leg without pain, and her hip and pelvic floor muscle strength improved. After six months, she had returned to running, and had recently completed a marathon without pain (9).


In summary, augmenting treatment with the addition of direct pelvic floor interventions in each of the above cases significantly improved each person’s remaining symptoms, and allowed them to return to their prior activities without restrictions. This demonstrates the importance of considering the pelvic floor in the diagnosis and treatment of hip pain – these patients both had injuries that were initially missed because the pelvic floor was not considered as a possible cause of hip pain, yet emerging evidence is linking pelvic floor dysfunction to otherwise intuitively unrelated injuries. This also highlights the need for further research in this area to minimize the occurrence of unnecessary procedures and medications, and to ensure that individuals can return to their daily activities with minimal disruption of their quality of life.

If you or someone you know is struggling with unresolving hip pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information! We are offering free phone consultations at both offices for a short period!

Thank you so much for reading our blog.

Katie Parrotte, PT, DPT, OCS, CFMT practices at our Midtown Location

K5 (2)



  1. Prather H, Colorado B, Hunt D. 2014. Managing hip pain in the athlete. Physical Medicine and Rehabilitation Clinic of North America, 45(4), 789-812.
  2. Cross M, Smith E, Hoy D, et al. 2014. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases, 73(7), 1323-1330.
  3. Osteoarthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/ osteoarthritis/diagnosis-treatment/drc-20351930.
  4. Continence Foundation of Australia. Pelvic Floor Muscles. Retrieved from: https://www.continence.org.au/pages/how-do-pelvic-floor-muscles-help.html.
  5. Drake R, Vogel AW, Mitchell AWM. 2009. Grey’s anatomy for students. Elsevier Health Sciences.
  6. Navot S, Kalichman L. 2016. Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization. Journal of Bodywork and Movement, 20, 604-609.
  7. Timmer CAW. 1991. Cycling mechanics: a literature review. Journal of Sports Physical Therapy, 14(3), 106-113.
  8. McGalliard M, Sizer PS, Ezell D. 2016. Current concepts of orthopedic physical therapy, 4th edition. (p. 7) Orthopedic Section – APTA.
  9. Podschun L, Hanney WJ, Kolber MJ, et al. 2013. Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International Journal of Sports Physical Therapy, 8(4), 462-471.
  10. Running Biomechanics. Retrieved from https://www.physio-pedia.com/Running_ Biomechanics.