Diastasis Recti

Picture from Lamaze.org

I saw a patient this week who had given birth to her second child about 3 months ago. Her friend told her that her belly was sticking out and the bulge may remain for months or years post partpartum. 

She has diastasis recti of about 2 fingers width. She was afraid that she would have low back pain and incontinence if the diastasis recti was not corrected.

Diastasis recti (DR) is the separation of the rectus abdominis (or 6-pack ab) muscles during and after pregnancy. The rectus abdominis runs in a straight line along the front of your stomach. A band of connective tissue called the linea alba divides the rectus abdominis into left and right sides. In simple terms it is the separation of the six-pack muscles into 2 halves.

It happens when the rectus abdominis muscles separate during pregnancy after being stretched. The linea alba becomes thinner and gets wider as it gets pushed by the uterus when it expands. The criteria for the diagnosis of DR is a gap or separation of more than 1.5 cm at one or more points of the linea alba.

Here is how I measure/check for the tummy gap. I get my patient to lie supine with knees bent and hip width apart. I place 2 fingers above her belly button. Then I get her to slowly lift her head, neck and shoulders off the bed like a low level sit-up. I then move my fingers below and above the belly button length wise and feel for any gaps and whether I can fit more than 2 fingers width wise. It's easy to feel for the gap this way.

After the baby is delivered, the linea alba can retract as the connective tissue is highly elastic. It can retract (like a rubber band). This usually happens for some new mums, the linea alba repairs itself within 10-12 weeks. However, when the linea alba loses its elasticity from being overstretched (larger babies) and/ or from a second and third pregnancy, the gap widens in the rectus abdominis.

Many patients have been told (by healthcare practitioners) that if DR continues after 10-12 weeks, their stomach/ core muscles cannot function efficiently and cannot properly support the lumbar spine (low back) or stomach contents. 

These same healthcare practitioners that treat diastasis recti will NOT be happy reading what I write next. Yes, women with DR may have weaker abdominal muscles (and perhaps more abdominal pain) BUT no higher prevalence of pelvic floor disorders (or incontinence), low back pain and pelvic girdle (hip) pain than women without DR (Gluppe et al, 2021). 

In fact, subgroup analyses comparing women with severe and moderate DR to women without DR showed no difference in abdominal strength, pelvic floor disorders (incontinence), low back pain, pelvic girdle and abdominal pain (Gluppe et al, 2021). This is actually the first study to investigate possible consequences of DR in a subgroup of women with moderate to severe diastasis.

I did not come up with that. There are many published research contrasting all that BS (excuse my language) about getting low back pain if you don't 'fix' your diastasis recti (Benjamin et al, 2019).

These studies contradict the common belief there there is an association between diastasis recti and pelvic floor disorders.  It does not mean that you definitely need treatment if you have a gap in your tummy after giving birth. Do not allow others to frighten you by saying that you will have back aches/ pain, weak core, hip, pelvic girdle pain and even incontinence if you don't 'fix' it.

So did I manage to reduce the tummy gap in my patient? I did and that may have to be a different post.

References

Benjamin DR, Frawlwy HC, Shields N et al (2019). Relationship Between Diastasis Of The Rectus Abdominis Muscle And Musculoskeletal Dysfunctions, Pain And Quality Of Life: A Systematic Review. 105(1): 24-34. DOI: 10.1016/j.physio.2018.07.002

Giuppe S, Engh ME and Bo K (2021). Women With Diastasis Recti Abdominis Might Have Weaker Abdominal Muscles And More Abdominal Pain, But No Higher Prevalence Of Pelvic Floor Disorders, Low Back And Pelvic Girdle Pain Than Women Without Diastasis Recti Abdominis. Physiotherapy. 111:57-65. DOI: 10.1016/j.physio.2021.01.008

*Thanks to Kaylee and Vean for getting me the articles

Intense Static Stretching Versus Strength Training For Muscle Growth

Static stretching device

Who says that strength training is needed to make muscles bigger and stronger? A study published 2 days ago showed that intense static stretching of the pectoralis major (chest) muscles 4 times a week produced similar hypertrophy gains to strength training done 3 times a week. 

What? Just as effective as strength training? I was surprised to say the least. Well you know I am not a big fan of static stretching at all. Skeptical? I was too!

81 participants were allocated to 3 groups in this study. A static stretching group, strength training and control group. Pec stretching was done for 8 weeks, 4 days per week for 15 minutes per day. Those in the strength training group trained 3 times a week doing 5 x12 repetitions. All the subjects were instructed to maintain their regular exercise routine during the study. They exercised at least twice a week in a wide range of sports like fitness training, team sports or strength-endurance training. 

Results showed significant strength increase in the static stretching and strength training group compared to the control group. There were no significant differences between the static stretching and strength training group.

There was moderate muscle thickness increases in the static stretching and strength training group compared to the control group. Muscle thickness was measured using ultrasound imaging. There was actually no difference between the static stretching  and strength training group.

Range of motion test

In terms of range of motion (ROM), static stretching group had significant moderate ROM increases compared to the strength training group. No difference in ROM between the strength training and control group.

It has been suggested that the shared underlying physiological mechanism between stretching and strength training is the high stretching tension both produces to induce stretch mediated hypertrophy (Warneke et al, 2023). This tension translates into chemical signals that stimulate anabolic processes to generate new muscle tissue.

Wow. Increased size, strength and range in 8 weeks compared to strength training. However, note that static stretching via a stretching device like in this study needed a second person to assist and adjust the stretching device. Moreover, regular strength training can prevent osteoporosis and sarcopenia.

References

Warneke K, Wirth K, Keiner M et al (2023). Comparison Of The Effects Of Long-lasting Static Stretching And Hypertrophy Training On Maximal Strength, Muscle Thickness And Flexibility In The Plantar Flexors. Eur J Appl Physiol. 123(8): 1773-1787. DOI: 10-.1007/s00421-023-05184-6

Wohlann T, Warneke K, Kalder V et al (2024).Influence Of 8-weeks Of Supervised Static Stretching Or Resistance Training Of Pectoral Major Muscles On Maximal Strength, Muscle Thickness And Range Of Motion. Eur J Appl Physiol. DOI: 10.1007/s00421-023-05413-y

Do Not Inject The Bursa

R subacromial bursa

I was very surprised when I came across the following findings from a research paper. Whether an accurate placement of corticosteroid injection into the subacromial bursa for subacromial pain (or shoulder impingement) resulted in decreasing shoulder pain and disability (Chung et al, 2022)

A bursa is small sac (or bag) filled with fluid. They act like thin shock absorbers between the bones and other moving parts of the body like muscles and tendons to reduce friction. When a bursa gets irritated (or inflamed) it fills up with more fluid resulting in a condition called bursitis. We have many bursae (plura for bursa) in our hip, elbow and knee joints.

Researchers reviewed video images of ultrasound guided corticosteroid injections to rate the accuracy of injection into 3 groups. Group 1: Definitely/ probably not in the subacromial bursa. Group 2: Probably in the subacromial bursa and Group 3: Definitely in the subacromial bursa. 

There were a total of 114 subjects. 22 were categorised in Group 1, 21 into Group 2 and 71 in Group 3. I definitely expected the subjects in Group 3 to have the best result, but I was wrong. 

Results showed that there were no significant differences between the 3 groups at 6 weeks. So, no clear evidence that accurately injecting the subacromial bursa under ultrasound guidance is better than missing it. Even if the injections were done *blind versus guidance by ultrasound! 

*Blind means the injection is done at the point where the patient says the pain is versus using ultrasound to guide the injection into the correct inflamed area.

The authors concluded that the accuracy of injection placement in shoulder impingement did not influence pain and function suggesting that improvements in patients' outcome did not require ultrasound guidance.

Perhaps there is no difference in outcomes possibly because neither 'blind' nor ultrasound guided corticosteroid injections work in the medium to long term. The sample size is small and follow-up period is too short. Plus y'all know how I feel about steroid injections.

Another systematic review also investigated ultrasound guided versus landmark injections for rotator cuff related pain (Adamson et al, 2022) and came to the same conclusions.

Will these findings affect the doctors/ surgeons who charge more using ultrasound guided injections compared to doing the injections 'blind'?

And another paper (Marshall et al (2023) showed that the subacromial bursa promoted an early inflammatory response in an injured tendon to help healing. Using a rat to model rotator cuff injury and repair, the bursa protected the tendon adjacent to the injured tendon and maintained the structure of the underlying bone. 

I do not normally consider results from obtained from animal studies usually (rats in this case), but am persuaded in this case as every time a 'diseased' or damaged body part is deemed worthy of removal or function suppressed, we find out later it is a bad idea. Like our tonsils and meniscus.

Inflammation and healing are definitely misunderstood. Our busae release essential inflammatory fluid/ cells for help our injured tendons recover. Injecting them with cortisone/ steroids means hindering the body's own healing process and harming your own tendons. Think of it as the human body is being programmed to sort out its own injuries.

References

Adamson N, Tsuro M and Adams N (2022). Ultrasound-Guided Versus Landmark-Guided Subacromial Corticosteroid Injections For Rotator Cuff Related Shoulder Pain: A Systematic Review Of Randomised Controlled Trials. Musc Care. 20(4): 784-795. DOI: 10.1002/msc.1643

Chean CS, Raval P, Ogollah RO et al (2022). Accuracy Of Placement Of Ultrasound-Guided Corticosteroid Injection For Subacromial Pain (Impingement) Syndrome Does Not Influence Pain And Function: Secondary Analysis Of A Randomised Controlled Trial. Musc Care. 20(4): 831-838. DOI: 10.1002/msc.1634

Marshall BP, Ferrer XE, Kunes JA et al (2023). The Subacromial Bursa Is A Key Regulator Of The Rotator Cuff And A New Therapeutic Target For Improving Repair. bioRxiv (Preprint). July 2. DOI: 10.1101/2023.07.01.547347

Should Only Top Athletes Get Sponsorship?

I was in Australia for the past 2 weeks and happened to come across news of a 400m runner, Alica Schmidt of Germany. Questions arose on social media on why she was being sponsored by Hugo Boss despite her not so stellar performances on the track.

Schmidt's Hugo Boss ad

Though she had represented Germany at world and European level, and made the 4x400 m relay at the 2020 Olympics,  she did not compete at the Olympics. She has also never won a major individual title. Actually, she 'only' ran the 147th fastest time in the 400m in 2023. 

Schmidt revealed that she only gets 700 Euros while representing Germany so it is impossible to make a living from athletics. Her main source of income comes from social media where she has 4.8 million followers on Instagram and 2 million follwers on Tiktok which helps her pursue her sporting career.

Bella Hadid's picture from Nike 

This hate or backlash is is not new. Back in 2017, Nike announced that fashion model Bella Hadid would be the face of its previously popular Cortez sneaker, designed in 1972 for runners. If you're an older runner you will remember the Cortez, after all even Forrest Gump (pictured below) used it for his runs.

Picture from Sneaker news

The Cortez was being re-released as a fashion/ lifestyle sneaker. This followed a series of fashion models being chosen to front the campaigns of other sportswear brands - Kylie Jenner (Puma), Karlie Kloss (Adidas) and Gisele Bundchen (Under Armour) just to name a few.

Naturally, some professional athletes have picked up on this back then and commented against this trend (pictured above).

If you were the decison maker at Hugo Boss, would you also pick Schmidt? Both athletes and models can be influencers/ ambassadors for brands. Just because Schmidt is not a world or Olympic athletics champion means she is less valuable to Hugo Boss since Hugo Boss is not a sports brand. 

Shaunae Miller-Uibo

Schnidt has great looks, blond hair and blue eyes, essential in the entertainment industry but not mandatory in the sports arena. She will be able to showcase Hugo boss to a wider audience and increase their sales. She may actually bring more audience to athletics. Shaunae Miller Uibo (pictured above) won the 400 m event at the 2016 and 2020 Olympics. She looks good too, but would you pick her over Schmidt if you were looking for someone to front your campaign?

Should only top athletes get sponsorship? iI's a dog eat dog world out there. Athletes (and models) have short sporting lifespans and that can all end with a single major injury. So I say let all athletes and models take advantage of what they have while they can be it sporting ability, personality or looks.

Farewell 2023

Sunset at Cowrie beach, Melbourne

Time really has flown by. It's the last day of the year as I type this final post for 2023 in Melbourne, Australia.

As the sun sets on 2023 and we welcome 2024 on the horizon, here are some of my thoughts before we ring in the new year. 

I sustained a paper cut on my finger last week while leafing through some books and magazines. The cut is super tiny, almost invisible but still hurts a fair bit. 

This is always an analogy that I give my patients about the many injuries and the subsequent pain they feel. The pain is not always proportional to the actual tissue damage . Remember this the next time you hurt your neck , back, knee or roll your ankle. Or other body parts.

For those of you who have eaten too much (like me) over the festive season and not kept up with your regular exercise routines,  here are some suggestions for getting in some activity no matter where you are: 

Find and do any exercise you enjoy. Some (or even a tiny bit) is better than none. More is almost always better. Walking and climbing stairs count too. 

Both weight (or strength) training and aerobic training are important but the best exercise is the one that gets done.

Whatever amount of exercise you are capable of today, that will be enough. Do that amount. Just start.

At Ripples N Tonic farmstay

Have a great 2024! 

Still Walking With Crutches After One Month?

Picture from Goal.com

Neymar Junior is definitely a world class footballer who just had an ACL reconstruction after tearing his anterior cruciate ligament (ACL) on 181023. However, his rehabilitation does not seem world class at all. 

You can hear him yelling when his knee is being forced to bend (knee flexion) with 3 people involved. I am not sure if the video was put up just to garner more views, but that is not what to do if you want to improve knee bending range. Getting full extension (knee straightening) is more important early on to avoid any chance of getting a cyclops lesion. 

And still walking with crutches after one month? Our patients are sometimes discharged and walking with no crutches from the hopsital or our clinic after a few days.

Come see us in our clinics if you need rehabilitation after your your ACL reconstruction.

Iliopsoas Related Groin Pain

Previously I have written about hip adductor related groin pain (ARGP), which is the most common area for groin pain. There is also iliopsoas related groin pain (IRGP). Patients who have IRGP usually have iliopsoas tenderness/ pain while stretching the area  and have pain with resisted hip flexion (or bending). 

There is not enough evidence to suggest which exercise protocol or treatment technique is superior for treating IRGP. However, there is evidence to suggest a quicker return to sports (and to running) using a multi-modal program (manual therapy, stretching, heat and exercise therapy) compared to exercise therapy alone (Weir et al, 2010).

Strengthening the iliopsoas via isometric, concentric and eccentric contractions using elastic bands for 6 weeks have been found to substantially improve iliopsoas (hip flexor) strength (Thorborg et al, 2016). King et al (2018) found that athletes had high rates of pain free return to sports participation and had improved cutting performance when rehabilitation focused on inter-segmental (lateral hip, legs and abdominals) control.

Neutral spine, anterior or posterior tilt

There you have it, no magic stretches, protocol, nor any therapeutic machine to really treat groin pain on its own. Some physios teach core or stabilization exercises with a neutral spine (pictured above).

3 planes of motion

Like I wrote before, we do see many patients with groin pain in our clinics. Our approach to treatment is very different. It depends on what our assessments show. The patients do not do any strengthening exercises when they are in the clinic. We prefer to treat them using mostly our hands instead. Since the pelvis (or hip) has 3 planes of motion, we treat them with our hands with respect to he 3 planes of motion (pictured above).

For example, for a patient with groin pain, they may also have a hip rotated to the right side (pictured below). 

Hip rotated to right side

We can treat the hip with respect to the shorter side. Short in terms of length. So the right side is shorter in front (pectineus) in the picture above, while the left hip is shorter behind. 

The patients can then do the strengthening exercises they need on their own. We treat what they cannot do themselves in the time they have with us. Come see us in our clinics if you have groin pain.

References

King E, Franklyn-Miller A, Richter C et al (2018). Clinical And Biomechanical Outcomes Of Rehabilitation Targeting Intersegmental Control In The Athletic Groin Pain: Prospective Cohort Of 205 Patients. BJSM. 52(16):1054-1062. DOI: 10.1136/bjsports-2016-097089

Thorborg K, Holmich P, Christensen R et al (2011). The Copenhaen Hip And Groin Outcome Score (HAGOS): Development And Validation According To The COSMIN Checklist. BJSM. 45(6): 478-491. DOI: 10.1136/bjsm.2010.080937

Weir A, Jansen JA, vande Port IG et al (2011). Manual Or Exercise Therapy For Long-Standing Adductor-Related Groin Pain: A Randomised Controlled Clinical Trial. Manual Therapy. 16(2): 148-54. DOI: 10.1016/j.math.2010.09.001