Diastasis Recti In People Assigned Male At Birth

Introduction

Diastasis rectus is a condition that occurs when there is an excessive amount of pressure exerted on the abdominal muscles. This is also known as intra-abdominal pressure.  As a result, the abdominal muscles become separated from each other which allows the organs to protrude against the abdominal wall. This condition commonly affects people during and after pregnancy and is due to the immense pressure put on the muscles as the uterus grows. However, in a review conducted, studies have shown that out of the 2291 patients, almost 224 men (9.8%) suffered from it.¹ Although there is a minority of people assigned male at birth (AMAB)  that suffer from this condition, it is yet to be properly studied in this population, as there are many factors that contribute to it.

About Diastasis

What is Diastasis Recti?

Diastasis recti are diagnosed as an abnormally wide distance between the two rectus muscles (also known as the abdominal muscles or abs). The front of the abdominal wall is composed of the two abdominal rectus muscles (abs) and is separated by a tendinous, fibrous structure known as the linea alba, that runs vertically down the midline of the abdomen between the two muscles. The linear alba is also fused with the external and internal oblique muscles and the transversus abdominis aponeurosis (a thin membranous sheath that is above the muscles). The normal distance between the two abdominal rectus muscles is 2 cm, therefore, anything greater than that is considered abnormal. 

Causes/Risk Factors

The causes of diastasis recti in men can be broadly divided into four factors:

• Muscle Imbalance: It has been observed that men with diastasis recti usually have over-developed external core muscles (e.g. abs and obliques) and under-developed internal core muscles (e.g. transverse abdominis). The instability of the core causes the body to recruit the use of other muscles (from the upper and lower body) to compensate. Compensatory patterns such as holding your breath and tensing the muscles can exert outward pressure on the abdominal wall. Over time, this pressure causes the linea alba to stretch, widening the distance between the abdominal recti. Exercises that particularly put individuals at risk include heavy lifting, sit-ups or crunches, front planks, and push-ups.² 

• Excess Weight and Obesity: People AMAB  living with excess weight and obesity are the second most common group of diastasis recti.³ The accumulation of central fat in the abdomen can put pressure on the linea alba and cause it to stretch, which in turn can lead to diastasis recti. Studies have shown that people with AMAB  are more susceptible to obesity due to hormonal changes than people assigned female at birth (AFAB) .⁴

• Familial History: Interestingly, familial history can determine whether people with AMAB  are susceptible to diastasis recti. Collagen fibres are the scaffolding structures that make up the muscles, and individuals can have varying types of collagen. Type I Collagen is strong structural collagen, whereas Type III Collagen has a weak structure. Low levels of Type I Collagen and high levels of Type III collagen in the midline of the abdominal wall can cause diastasis recti. Hereditary connective tissue defects such as Ehler–Danlos syndrome and abdominal wall hernias can increase the chances of diastasis recti fourfold.³

• Other Diseases: Other acquired diseases such as HIV, chronic obstructive pulmonary disease, cirrhosis of the liver, abdominal wall cancer, or pelvic floor dysfunction have been reported to increase the risk of diastasis recti in men.^{5 6} Diastasis recti usually occurs as a cumulative effect of long- or short-term swelling of the abdomen related to the fluid inside of the abdominal cavity.

• Age: Age can be a determining factor as to whether men can get diastasis recti, this is because as they get older, the health of the muscles gradually declines, making them unable to be supportive structures.³

• Gender: Anatomical structures are different in people AMAB  and people AFAB. Upon studying anatomy in people with AMAB, it was found that they have significantly less stiffness in the linea alba when compared to people with AFAB. This is due to them having less fibrous material than people AFAB, which makes them more prone to acquiring diastasis recti.⁷ 

Symptoms

There are physical markers in both people AMAB  and AFAB  that show that they have diastasis recti. People with AMAB, typically have the recti muscle separation in the upper portion of their abdomen, whereas, in people with AFAB, this is closer to the lower portion of their abdomen (where the uterus is). When people AMAB  sit up from a lying down position or are in a crunch position, there is a vertical bulge in the centre of the abdominal wall. 

Other symptoms of diastasis recti include: ²

 Created by Aastha Malik

Diagnosis

Diagnosis of diastasis recti is usually done through a physical exam. A doctor will ask you to lie flat on your back, and then perform a half sit-up or a crunch. If a vertical bulge appears in the centre of your abs, you will be diagnosed with diastasis recti. 

The doctor may also use the Tupler technique. They will ask you to lie on your back with your knees bent, your head flat on the floor, and your arms to your side. They will then place either one or two hands on your belly button and ask you to relax your abdominal muscles. After this, they will then ask you to lift your head just a little and see how many fingers fit between the two separated muscles. The doctor will determine the largest gap, the higher you bring your head up, the closer the muscles will come together. This will be checked for in three different places: at the belly button, above the belly button (about halfway between the belly button and sternum), and below the belly button (about halfway between the belly button and the pubic bone). The doctor will also check the condition of the connective tissue. They will do this by placing one finger in your belly button and checking how far down the finger goes. The deeper it goes, the weaker the connective tissue. The doctor may also employ tools such as callipers, CT scans or ultrasounds to measure the distance of the gap between the muscles and  assess the severity of your condition.⁸ 

Treatments

There are two forms of treatments for diastasis recti; exercise or surgery (or both). The mode of treatment adopted depends on the severity of the condition.

• Exercise: Core strengthening exercises can be adopted to resolve minor effects of diastasis recti. These exercises are usually put in place by a physiotherapist. The aim of the exercises will be to strengthen the core and be mindful of correct posture when exercising. Some of the common exercises used to focus on diaphragm strengthening, abdominal braces and core stabilisation. Tupler technique exercises such as the elevator exercise, contracting exercise, and head lift exercise can be done to reduce ab separation and strengthen connective tissues. 

• Surgery: Surgery may be employed for more severe cases of diastasis recti. However, with surgery, the condition recurred as often as 40% of the time.^{8 9} There are three types of surgery that can be done: 

1. Conventional Surgery: This is done via an incision in the abdomen, such as abdominoplasty, or a tummy tuck. This type of cosmetic surgery also removes excess skin, tissue and fat from the abdomen.
2. Laparoscopic Surgery: This is done via a small incision, where a tube that guides light, a camera, and surgical tools is inserted into the affected area. 
3. Endoscopic Surgery: This is done via a small incision, where a tube that guides light, a camera, and surgical tools is inserted through the throat and oesophagus rather than directly through the abdomen. 

The complications that can occur with surgery include:

• Pain after surgery
• Nerve damage
• Wound infections
• Rupture of the wound
• Hematomas (a solid swelling of clotted blood within the tissues)
• Minor skin loss

Is Diastasis recti painful?

The separation of the ab muscles itself is not painful. If the pain does occur, it is due to a side effect of the other symptoms such as weakness in the core, hips and back, where the body is unable to support itself.

What happens if Diastasis recti go untreated?

If diastasis recti are left untreated, the associated pain and symptoms can become worse. Eventually, it can cause incontinence and prolapse (protrusion of the organs).

Summary

The severity and recovery of diastasis recti is unique to the individual. In many cases, the condition can be corrected by core stabilising exercises with the help of a physical therapist. Individuals that opt for surgery usually do so because their associated symptoms are severe, or else for cosmetic purposes. In both cases, recovery is successful with proper care and correct posture during exercises.