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Why Surgery Isn’t the Answer for Diastasis Recti Abdominus

My latest contribution to the Core Expectations blog:

Surgery is often suggested to repair a Diastasis Recti (separation of the rectus abdominal muscles). My clients often ask me if they are candidates for surgery, and there is both a short and a long answer to this question. The short answer is “unlikely.” In my experience, surgery for a Diastasis is a rare case scenario. 

What determines the small percentage of women who require surgery to repair a Diastasis Recti?

The inability to create any tension in the linea alba with proper core cueing may be a surgical situation – with no functional core support the system is weak and vulnerable to injury – but it is still a long process to say that definitively. 

Here’s the long answer.

If after teaching a client effective cues to recruit the core 4 muscles (diaphragm, pelvic floor, transverse abdominis and multifidi), she is unable to generate tension in the linea alba, more work is prescribed as homework in the hopes that with practice this will improve. Upon reassessment if she is still unable to generate tension with any of the cues provided it is time to insist on a visit to a rostered pelvic floor physiotherapist.

An internal assessment is the most definitive way to assess tone, strength and function of the pelvic floor muscle. A weak pelvic floor muscle will inhibit the ability of the transverse to effectively recruit and create tension in the abdominal wall. A pelvic floor physiotherapist can release any trigger points or scarring that may be causing hypertonicity in the pelvic floor, assess any degree of pelvic organ prolapse, as well as determine which cue truly is best for any particular client. The client is sent back to the trainer, with a follow-up scheduled to assess progress.

Cued dynamic movements may be introduced prior to stationary core 4 movements being mastered, in an attempt to “tap into” any automation that may be happening. A pelvic floor physiotherapist may ask for a year of exercise to say definitively that absolutely no tension is being created in the connective tissue. If tension does improve, the client is able to strengthen the muscles, although this may take a lot of time and effort. Choosing to avoid the commitment to exercise rehabilitation does not make a client “surgical” in my opinion.

The goal of core rehabilitation is to create a functional core: one with both the strength to create and the endurance to sustain myofascial tension that supports everyday movements, as well as exercise. A core may be “functional” with a small diastasis still present. If a client considers surgery at this point, it is often aesthetic and unnecessary from a strength and fitness perspective.

For that small percentage of surgical cases, I feel a tremendous amount of empathy. Surgery is a last resort as by its very nature it can inhibit optimal core recruitment forever. It is not a “fix;” but in rare cases it is the only viable option. Abdominoplasty is a major surgery resulting in scarring and myofascial immobilization. It’s invasive, mentally taxing, expensive, and the recovery is long. A surgically reinforced core is not “strong” by fitness standards; surgeries can fail and pre/post-op core 4 exercise is still a must. You don’t ever avoid the work of core rehab if you truly want to be strong.
The “S” word is a last resort.

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