What is the best treatment approach for a postpartum patient with divarication of recti (abdominal) muscles?

Treatment for Diastasis Recti Abdominis

Conservative physiotherapy with structured abdominal core training is the first-line treatment for postpartum diastasis recti, and surgical intervention should only be considered after 6 months of failed conservative management in patients with functional impairment and diastasis width ≥5 cm. 1

Initial Assessment and Diagnosis

• Measure the inter-recti distance using a caliper or ruler during clinical examination, with the patient supine and head slightly elevated to engage the abdominal muscles 1
• Obtain ultrasound imaging when concurrent umbilical or epigastric hernia cannot be excluded clinically, or when other causes of symptoms need evaluation 1
• Document the location and width of maximal separation, as this guides treatment decisions 1

Conservative Management (First-Line Treatment)

All patients should undergo a minimum 6-month structured physiotherapy program before considering surgery. 1

Exercise-Based Interventions

• Abdominal exercise programs are generally effective for treating postpartum diastasis recti at various time periods, with evidence showing 35% reduction in DRAM presence when exercise is performed during the antenatal period 2, 3
• Core strengthening and targeted abdominal exercises form the cornerstone of conservative treatment, though the optimal exercise combination remains unclear due to heterogeneity in research protocols 2, 3
• Electrical stimulation combined with exercise shows preliminary but promising efficacy and may be considered as an adjunct to standard exercise programs 2
• Abdominal kinesiotaping can be used in conjunction with other interventions as part of a multimodal conservative approach 2

Important Caveats for Conservative Treatment

• The evidence quality for exercise interventions is generally poor, with studies using different measurement methods (palpation, calipers, ultrasound) and evaluation timeframes 2, 3
• Non-specific exercise may or may not help prevent or reduce DRAM, as the available evidence is limited and of low quality 3

Surgical Management Criteria

Surgery should only be considered when ALL of the following criteria are met: 1

1. Diastasis width ≥5 cm at the point of maximal separation (smaller diastasis may be considered with pronounced abdominal bulging or concomitant ventral hernia) 1
2. Documented functional impairment affecting quality of life 1
3. Failed 6-month standardized abdominal core training program 1
4. At least 2 years elapsed since last childbirth 1
5. No future pregnancy planned 1

Surgical Technique

• Plication of the linea alba is the first-line surgical technique, with no other techniques proven superior 1
• Extended miniabdominoplasty with low suprapubic incision and umbilical caudalization avoids periumbilical scarring and is particularly beneficial for young, slim women with post-pregnancy abdominal wall deformity 4
• Strengthening of incompetent aponeurotic formations with mesh reinforcement may be considered in complex, long-standing cases, with no recurrences reported in long-term follow-up 5

Surgical Complications

• Minor wound dehiscence in the middle portion of the incision occurs in approximately 16% of patients and is typically managed conservatively 4
• Mild relaxation of lateral abdominal muscles may occur postoperatively, requiring elastic bandage support for some patients 5

Common Pitfalls to Avoid

• Do not proceed to surgery without documenting completion of a full 6-month physiotherapy program, as this is the evidence-based standard of care 1
• Do not operate on patients planning future pregnancies, as this will likely result in recurrence 1
• Do not rely solely on patient-reported diastasis width—always measure objectively with calipers or imaging 1
• Do not assume all abdominal bulging is simple diastasis—rule out concurrent hernias with imaging when clinically indicated 1