What is the management approach for diastasis recti?

Management of Diastasis Recti

Physiotherapy with targeted abdominal core strengthening exercises is the first-line treatment for diastasis recti, and surgery should only be considered after a standardized 6-month exercise program has failed in patients with functional impairment and diastasis width ≥5 cm. 1

Diagnostic Criteria

• Diastasis recti is diagnosed clinically when the inter-rectus distance exceeds 2 cm, measured using a caliper or ruler during physical examination 1, 2
• Diagnostic imaging with ultrasound should be performed when concurrent umbilical or epigastric hernia cannot be excluded, or when other causes of symptoms need evaluation 1
• The largest width of the diastasis should be measured and documented, as this guides surgical decision-making 1

Conservative Management (First-Line Treatment)

All patients should undergo physiotherapy before any surgical consideration 1

Exercise Therapy Approach

• Targeted abdominal/core strengthening exercises are the primary conservative intervention, with evidence showing a 35% reduction in DRAM presence when performed during the antenatal period 3
• A standardized 6-month abdominal core training program must be completed before surgical treatment is considered 1
• Exercise therapy combined with abdominal binding shows positive effects on body image (Cohen's d = 0.2-0.5) and trunk flexion strength (Cohen's d = 0.7) 4
• Compliance rates exceed 50% for structured exercise programs, making this a feasible intervention 4

Important Caveats for Conservative Management

• The correlation between anatomical correction and symptom improvement is often weak, as underlying functional disorders may not be corrected by exercise alone 5
• Exercise may or may not help prevent or reduce diastasis based on current evidence quality, but it remains the recommended first approach 3

Surgical Management

Surgery is reserved for patients with functional impairment who have failed conservative management 1

Surgical Candidacy Criteria

• Diastasis width must be at least 5 cm at its largest point before surgical treatment is considered 1
• Surgery may be considered with smaller diastasis if there is pronounced abdominal bulging or concomitant ventral hernia 1
• At least 2 years must have elapsed since last childbirth, and future pregnancy should not be planned 1
• High-risk patients include multiparous women, obese patients, and those with multiple previous operations 6

Surgical Technique Selection

• Plication of the linea alba is the first-line surgical technique 1
• Abdominoplasty with plication of the anterior rectus sheath is commonly used but requires a wide skin incision 2
• Minimally invasive laparoscopic techniques using endo-stapler plication of posterior rectus sheaths with retromuscular mesh placement show promising results with no major complications in 74 patients, though longer follow-up is needed 2
• Other surgical techniques may be used but have not been found superior to standard plication 1
• Extensive plication of the anterior abdominal wall with or without mesh (resorbable or nonresorbable) may be required depending on severity 6

Surgical Outcomes and Complications

• Minimally invasive techniques report significant symptom reduction with low recurrence rates (2/74 patients at 6 months) and no postoperative infections 2
• Long-term outcomes require careful monitoring, as anatomical correction does not always correlate with symptom relief 5

Clinical Pitfalls to Avoid

• Do not proceed to surgery without completing a 6-month structured physiotherapy program first 1
• Do not operate on patients planning future pregnancies or within 2 years of last childbirth 1
• Do not assume anatomical correction will resolve all functional symptoms, as the correlation is often weak 5
• Ensure proper measurement technique using calipers or rulers rather than subjective assessment 1