Separated Rectus Abdominis (Diastasis recti) – are we rehabilitating them correctly?

Those therapists amongst you will know about Diastasis recti, a separation between the left and right side of the rectus abdominus muscle, which covers the front surface of the abdominal area. It is another name for the more commonly described Split Rectus Abdominus. It is caused by pregnancy and the rectus muscle being stretched by the baby in the uterus. It is most common in the later trimesters and more so with multiple births or repeated pregnancies.

A diastasis recti looks like a ridge, which runs down the middle of the abdominals. It stretches from the sternum to the navel and increases with abdominal muscle contraction. In the later part of pregnancy, the top of the pregnant uterus is often seen bulging out of the abdominal wall when rectus is engaged. An outline of parts of the unborn baby may be seen in some severe cases.

Post natally you can check if your client/patient has Diastasis recti by laying them supine with knees bent (crook lying) and get them to raise their heads. You commonly see a central ridge protrude in the centre of Rectus Abdominis and if you palpate above the navel you should feel a soft gap between two hard muscles. Measure the space of the gap using your fingers (this is called a Rec Check). If the gap is greater than two finger widths, your client/patient may be suffering from separated muscles.

No treatment as such will help pregnant women with this condition, although exercise may help, but there is limited evidence that exercise will resolve the problem. However postnatally conventional wisdom suggests that after any discomfort has settled it is reasonable to start some light abdominal work, but do not work the obliques initially. Understanding their origin and insertions reveals any oblique contraction will most likely exaggerate the split of Rectus. Conventional wisdom suggests to start with pelvic floor work and stabilising work using Transversus Abdominis (Trans Abs) with the pelvis in the correct position, then do co-activation work with pelvic floor then progress to try and shorten Rectus by doing inner range work. The production of relaxin (a hormone that is secreted in abundance when pregnant) effects the collagen make up in the linae alba (the central tendon in rectus abdominus) and may be a cause of the diastasis. As soon as the placenta is delivered the increased secretion of relaxin reduces to normal, but the effects can last for up to 5 months and breast feeding will keep it higher than normal until your client/patient has stopped. This may affect how quickly the Diastasis recti will reduce.

Please be careful while working Transversus Abdominis though. While conventional wisdom is sometimes right, it sometimes isn’t, let’s challenge it now. If you look at the origin and insertion of Transversus Abdominis and consider its function, logically when it contracts it will pull the rectus apart further, much the same as contracting the obliques would. There is no evidence to suggest that doing Trans Abs work is the right thing to do, its just something that we all do, without it seems, much thought as to why. Just think, if the Trans Abs inserts into the aponeurosis of rectus (anteriorly below the navel and posteriorly above the navel), any Trans Abs contraction should pull the rectus apart further. So why do we work Trans Abs initially with a diastasis recti?

Actually we’ve measured the split of rectus using Ultrasound scanning and it does separate further when Trans Abs is engaged. I am collaborating with a colleague, Mark Maybury, who is an Extended Scope Physiotherapist specializing in Ultrasound scanning, and we plan to do a paper on this – to challenge conventional wisdom in this field. We hope to have it completed in the next few months, please come back and see what we find, I’ll put the paper here when it’s completed.

What is your experience with this condition?

Possible Leg Length Discrepancy

Hi Martin

I am working with an athlete and have just done the normalise tests with him.

His left leg is 5 to 7 mm longer than his right. Downing’s test was fine so in my eyes suggests that he has actually got one leg longer than the other. Gillett’s test was positive (there did seem to be a little movement on both sides but not great).

In his upper body there was high tone on right erector spinae in the thoracic spine, high tone on left upper traps, mild left scapula winging when standing and rotated to the right (right shoulder back, left shoulder forward) sway back posture.

What is the best way ahead? If he does have a leg length discrepancy, do we pop an insert in the shoe of the shorter leg? This would obviously mean dramatically altering his training for a long period for his body to adjust. Do we leave it? The athlete is 18 years old and is currently on 30 miles a week. He has been up to 40 miles a week last cross country season. He and his coach are looking to up the mileage to 50 for this cross country season. He has no history of any injury. I think this may change though when the mileage goes up. He is in the top 40 in England for 1500 metres in the under 20 age range. A very dedicated athlete.
I would welcome any comments you can make on this.

Hi ‘Coach’

He may indeed have a genuine leg length discrepancy if Downing's is negative. However if Gillett's is positive (and I notice on the screening form that the 4-sign is positive on the left side too) it is possible that his pelvis is still rotated, remember Downing's is just one way of establishing if the pelvis is functioning correctly. So I'd do the anti-spasm exercises and the exercises that work the other areas that biomechanically load the pelvis (all the other tests that are positive in the Normalise screening) and then re-measure.

When the pelvic (and other tests) come back negative, then see how the leg length discrepancy measures. If it's still longer then a heal raise may be appropriate depending upon the exact discrepancy. If that was the case I'd send him to an Orthotist or Podiatrist (or even a musculo-skeletal therapist who was experienced in this type of thing) for the prescription. If however the leg length has been reduced by the biomechanical work then we know it was from the pelvis and he may well not need a raise.

Generally though, there would need to be quite a good argument and significant discrepancy before we should consider heel raises for anyone.

I hope that helps.

Martin

I’ll let you all know how this athlete gets on with that advice and see how he improves over time.

Visit Mobilis Performance at the LIW, Birmingham NEC, Stand 5150

Mobilis Performance will be attending the Leisure Industry Week (LIW) show at the NEC in Birmingham, 23rd – 25th September, on Stand 5150.

"Leisure Industry Week is the ultimate event for everyone in the leisure industry. It’s the show that attracts thousands of leisure professionals for hundreds of different reasons every year" (LIW, 2008).

In addition to promoting the ‘Biomechanical Screening courses for Injury Prevention and optimal performance’, we will be carrying out biomechanical screens that you can use on your clients throughout the 3 days. Or, just drop in for chat about our courses and our up and coming Diploma which will qualify Personal Trainers as 'Biomechanics Coaches'.

Also, WIN PRIZES!

Free prize draw; Put your business card or details in to the draw pot and you could win:

1st Prize – a FREE Normalise course
2nd Prize – 25% discount on a course
3rd Prize – 10% discount on a course

See you there!

For more information on Leisure Industry Week please visit the official LIW website.

Dwain Chambers Saga Finally Put To Rest

Its been a long time since good sense prevailed, but at last the Dwain Chambers affair has been put to rest. Actually it was quite simple, he entered competitions with a full understanding of the rules and that if he took certain drugs he would be band for life. He broke the rules and was band for life. That’s it, isn’t it? Of course he then tried to change the rules in a vain attempt to clear his name, but even those who are usually too politically correct to make sensible and fair decisions saw sense in this case. Now let’s get on with the Olympics.

The MBT Trainers Debate

Well, the MBT trainers continue to cause huge debate, and now they’ve been around for a little while, serious questions are being asked about their long term effects. Interestingly the answers are inconclusive at best.

A Sheffield Hallam University study concluded that wearing MBTs was better for the knees, hips and ankles than wearing conventional shoes. It would be interesting to learn how they are defining ‘better’ as many are questioning the effects.

Our work using video analysis has demonstrated that the shoes can be so unstable that they often encourage over pronation. The problem is that the majority of us have over pronation issues, the instability and malalignments from which causes extra pressure on musculo-skeletal structures so they become overloaded by attempting to compensate and eventually fail. We know this because for many years podiatrists and Orthotists have been trying to minimise the effects of over pronation, and when prescribed correctly, orthotics often helps the individuals pain and performance.

One main reason why MBT claim that their shoes increase the amount of muscle work is because it loads the muscles so they’re working harder than normal, well that would be right in this case as they’re working over time to compensate for the negative instability from the shoe. As Dr David Johnson, consultant orthopaedic surgeon at St Mary’s Hospital in Bristol, says: “The claims as to assisting posture, back, hip and knee problems are not supported by evidence or any good rational explanation. Indeed the instability provoked will increase the muscle activity and energy required to walk – thus increasing fatigue and tiredness.” If you are one of the few who have supinated or very arched and rigid feet, then this instability and extra shock absorption is a good thing, if not it can be harmful over time.

There is little evidence that they help with the removal of cellulite either. According Esther Walker of the Independent Extra, “this is backed up by Hannah Snow who wore MBTs daily for two years and found they toned her muscles but did not get rid of the fine layer of cellulite on the top of her legs”. Well, they will work the legs harder as the shoes are so unstable that the leg muscles have to work unusually hard to stabilise the legs. Harder in this context isn’t necessarily better.

Esther Walker also reports that Sammy Margo of the Chartered Society of Physiotherapists believes that MBTs are not necessarily a bad thing but that they are not for everyone: “They can possibly help people with stiff backs, who do jobs that involve a lot of standing. Ideally, you should get them only on the recommendation of a physiotherapist and should be trained to use them properly. They are not a cure-all for modern life.”

So despite the PR machine’s claims, nothing is the panacea for all ills. Obviously MBTs, like anything, has its place and will help some people, but be sure to establish whether you’re likely to be one of them first.

Unleashing the sporting potential our country has to offer

Well, its that time of year again and the Wimbledon Tennis is upon us. It’ll no doubt be another year of expectation heightened by the PR machines and then dashed by our seemingly innate inability to play tennis consistently at the highest level, despite the millions of pounds spent on developing tennis in the UK.

My feeling is that despite the amount of money being pumped into the sport, the main factor that is not being addressed adequately, is that this is a typically middle class, white sport. Until we can attract a broader mix of players at young age who are hungry to ‘get out of the ghettos’, we will never unleash the potential that this country undoubtedly has in its lockers. Come on the LTA, lets give free tennis courts and lessons to our under privileged kids and those kids who’s parent earn under a certain income and can’t afford to go to the fancy tennis clubs. Lets get the PR machine to look for our ‘Tiger Woods’ and lets try and make this great sport truly open to all.

The young player Murray is obviously our great hope and injuries apart will helpfully give us something to cheer this year. As many of my friends are Scottish, I’m well aware that he’ll be British if he wins and Scottish if he doesn’t! Good Luck Andy!

Participants from a wide range of specialist areas benefit from our courses

This weekend we probably had the most diverse group of participants on the biomechanics screening courses we run. There were physios, podiatrists, sports therapists, personal trainers, Pilates teachers and athletics coaches. It was a rich collection of skills and talent and a great group to work with.

The challenge with working with such a diverse group is making the content relevant to each arena. The personal trainers and coaches were interested in its application to injury prevention and optimal performance and the Pilates teachers were keen to learn about its application into their classes and private clients and how that plays into the management of back pain. The podiatrists were fascinated to learn how pelvic biomechanics could play into and compliment their orthotic prescription and the physios and sports therapists were interested in all of the applications.

The questions that came out from the group provided them all with a much broader view of how biomechanics can be applied across the different arenas, but also expanded on the application of the information into their areas as well. So all things considered a very positive weekend and we look forward to taking the group through the next 2 phases of the courses.

Course dates are available throughout the UK for the Mobilis Performance Intelligent Training Courses.

Physio First Conference - A Great Success!

We had a great show this weekend at the East Midlands Conference Centre in Nottingham. We were at the Physio First Conference to talk to Physios for the first time en mass about our Biomechanics Screening courses and their application to the clinical field. The interest was very positive and we are looking to set up many courses for Physios and other Therapists in the near future.

As many of your will be aware, one of our partner products is called the Flexi-bar . This is a flexible bar that provides the user with a very effective way of stabilising the shoulder and spine particularly. Its quite new to the physio worlds and went down a storm. As soon as they saw the product in action the biomechanical and clinical benefits were obvious. In fact they were suggesting applications to us!

Also this weekend we had a Normalise Course in Bristol which was run by Ros and Rachel, which went down really well. We had 2 Podiatrists, 4 athletics coaches and 8 personal trainers on the course. One of the great things about the courses that we are told by participants is the variety of backgrounds that people have who attend the courses. This then leads into some great discussions about the application of the biomechanics content that we deliver. One area of interest is usually the conversations around the application of orthotics to the sporting arena and how they can be so helpful and yet sometimes can cause all sorts of problems. When podiatrists sit the courses they start to have a better understanding of the big picture and how the pelvic biomechanics can influence the prescription of orthotics and how undertaking the full biomechanical picture can help orthotic prescription and reduce the risk of the athlete or gym-goer reacting negatively to them.

FitPro Spring Convention - Wow What a Great Show!

This was the first time we have been to FitPro and we were overwhelmed by the response from Personal Trainers (PT’s) and health clubs. We presented a technical presentation to a very enthusiastic audience, despite it being at 8am on the Sunday morning (and this was definitely the morning after the night before!). We also had an exhibition stand. This was very busy all weekend and was supposed to close at 3.30 on Sunday afternoon, and while other exhibitors were closing up at lunch time, we had guys queuing until 4pm to find out more about what we do.

The PT’s were fascinated by the concept of the biomechanical preparation they can provide for their clients and how it would improve not only their exercise prescription but also help manage the biomechanical causes of the many ailments that their clients often suffer from. As always we made it clear that the biomechanics programmes are not deigned in this context for treating people’s injuries, the whole idea is to help reduce the biomechanical causes, which can have a profound effect. We were providing free biomechanical screens (tests) to delegates to demonstrate how simple they were and quick to perform, despite being biomechanically valid.

It was also good to catch up with our friends from Flexi-bar and Power Plate and look at more ways that we can work together. In fact Flexi-bar very kindly donated a flexi-bar as one of our prizes which was won by a delighted PT!

Now we’re spending a lot of time working through the massive amount of interest and contacting people to provide them the info they’re after. If you’re one of them, you’ll be hearing from us soon!

FitPro Spring Convention

Well, it’s that time of year again and we’re busy preparing for FitPro, the one of the industries main fitness shows in the UK. As well as exhibiting at the show, we have a demonstration area where we can show PTs and coaches the best biomechanical screening techniques for their clients and athletes to help improve their functional training programmes. So please drop by so we can explain the sort of biomechanical screening that you can do to help your exercise prescription.

We will be joined on the stand by our friends from Flexi-bar from time to time over the FitPro weekend and we’ll be discussing how we link their flexi-bar and XCO products into our training courses.

Also, we’ve been invited to present at the show too. I’ll be presenting at 8am on Sunday 13th April. Yes, we’ll be discussing functional training and no doubt we’ll be discussing core training too. But perhaps more importantly we’ll be talking about how all the functional training in the world and all the core training in the world can work against you if you have poor biomechanics. If you try and pattern particular functional movements, in 3 planes using multi joint patterns for example, and your client has biomechanical problems (which is very common), you can be sure that they will ‘break’ or get injured sooner or later. Functional training is not new and we’ve been using it in rehab for years, so we cannot underestimate its importance, however as good as functional training and screening is, it’s critical that your clients are prepared biomechanically, otherwise you’ll find the functional training you are doing is merely teaching your client faulty movement patterns. And this ultimately leads to injury.

Although biomechanics can be very complex, and indeed the principles of our work is heavily research lead, the actual practical application is very simple. We have been teaching PTs and coaches the biomechanical screens for some time now and the feedback is incredibly positive – please drop by if you can, I think you’ll find our evidence based work very interesting and will hopefully help you think further out of the box than you already do.