How should pain be managed in an outpatient with diastasis recti and abdominal wall muscle spasms?

Management of Pain in Rectus Diastasis with Abdominal Wall Muscle Spasms

For outpatient management of rectus diastasis with muscle spasms, initiate cyclobenzaprine 5-10 mg at bedtime as an adjunct to physical therapy for short-term relief (2-3 weeks), combined with a structured core rehabilitation program. 1

Immediate Pharmacologic Management

Muscle Relaxant Therapy

• Cyclobenzaprine is FDA-approved specifically for relief of muscle spasm associated with acute, painful musculoskeletal conditions and should be used as an adjunct to rest and physical therapy 1
• Start with 5 mg at bedtime to minimize sedation, can increase to 10 mg if needed 1
• Limit duration to 2-3 weeks as adequate evidence for prolonged use beyond this timeframe is not available 1
• This addresses the spasm component directly while physical therapy addresses the underlying diastasis 1

Adjunctive Analgesics

• NSAIDs can be used for inflammatory pain control, particularly if there is associated abdominal wall inflammation 2
• Consider topical NSAID preparations for localized abdominal wall pain to minimize systemic side effects 3
• Avoid opioids completely - they are contraindicated for chronic musculoskeletal pain and worsen functional outcomes 4, 5

Physical Therapy as Primary Treatment

Core Rehabilitation Program

• Physiotherapy is the first-line treatment for rectus diastasis, though specific regimens require individualization based on severity 6
• Focus on exercises that strengthen the transverse abdominis and oblique muscles without increasing intra-abdominal pressure 6, 7
• Avoid traditional crunches or sit-ups that can worsen the separation 7

Expected Outcomes

• Physical therapy has demonstrated effectiveness for symptom relief including pain, though success rates vary in the literature 6
• Most patients with rectus diastasis experience improvement in pain, musculoskeletal symptoms, and quality of life with conservative management 6, 8

Assessment of Associated Conditions

Rule Out Complicating Factors

• Assess for herniation of abdominal viscera - while rectus diastasis is not a hernia per se, herniation can occur through the widened linea alba 7, 9
• Evaluate for associated low back pain, which is highly significantly associated with rectus diastasis 8
• Screen for pelvic floor dysfunction, particularly if the patient has had multiple pregnancies 8

Risk Factor Modification

• Address modifiable risk factors: weight management if BMI is elevated, as obesity is a significant risk factor for diastasis 8
• Screen for diabetes, which is an independent risk factor for rectus diastasis development 8

When Conservative Management Fails

Neuromodulator Therapy

• If pain persists beyond 4-6 weeks despite muscle relaxants and physical therapy, consider low-dose tricyclic antidepressants (10-25 mg at bedtime) for neuropathic pain components 3, 5
• Explain to the patient that this is a "gut-brain neuromodulator" that addresses central pain processing, not an antidepressant in this context 3

Surgical Referral Criteria

• Surgical repair (open or laparoscopic plication) should be considered if conservative treatment fails after 3-6 months 6
• Both open and laparoscopic approaches have high success rates with low recurrence and complication rates 6
• Surgery improves pain, quality of life, and associated symptoms like low back pain 6, 8

Critical Pitfalls to Avoid

• Do not prescribe opioids - they are inappropriate for this musculoskeletal condition and risk narcotic bowel syndrome 4, 5
• Do not use cyclobenzaprine beyond 2-3 weeks without reassessment, as prolonged use lacks evidence 1
• Do not delay physical therapy - it should begin immediately as the foundation of treatment 6
• Do not ignore associated low back pain or pelvic floor dysfunction - these require concurrent management 8

Multimodal Pain Strategy

Combined Approach

• Use cyclobenzaprine for acute spasm relief while simultaneously initiating structured physical therapy 1, 6
• Add NSAIDs for inflammatory pain control during acute flares 2
• Consider heat or cold application to the abdominal wall for additional symptomatic relief 4

Patient Education

• Explain that rectus diastasis is a structural problem requiring mechanical correction through exercise 6, 7
• Set realistic expectations: improvement typically occurs over weeks to months, not days 6
• Emphasize that muscle spasms are secondary to the underlying diastasis and will improve as core strength is restored 6