Pectus carinatum is a congenital deformity of the anterior (front) chest wall in which the sternum (breastbone) and the adjacent ribs bow outward. The name is derived from Latin, where pectus means “chest” and carinatum means “keel-shaped,” likening the shape of the chest to the keel of a boat. It is the second most common chest wall deformity after its opposite, pectus excavatum (a sunken or funnel chest).

To understand why this happens, it is essential to look at the anatomy of the chest wall.

• The rib cage provides a strong, bony structure to protect the heart and lungs.
• The sternum is the flat bone that runs down the center of the chest.
• The ribs are not connected directly to the sternum. Instead, they are joined to it by strips of flexible cartilage called costal cartilages. These cartilages give the chest wall its necessary flexibility for breathing.

A helpful analogy is to think of your rib cage as a strong, bony birdcage and your sternum as the central front bar.

• In this model, the costal cartilages are like short, flexible “rubber connectors” that attach the ribs to the central bar.
• In pectus carinatum, it is as if these rubber connectors are programmed to grow too long during the adolescent growth spurt.
• As these cartilages overgrow, they have nowhere to go but forward, and they push the central bar (the sternum) outward.
• This creates the prominent, bowed-out appearance of the chest. The problem is not with the bones themselves, but with the excessive growth of the cartilage that connects them.

There are two main types of pectus carinatum:

1. Chondrogladiolar: This is the most common type (about 95% of cases). The protrusion involves the middle and lower parts of the sternum, giving it a keel-like shape.
2. Chondromanubrial: This is a rarer and more complex type where the upper part of the sternum is pushed forward.

In my experience, adolescents often come in feeling self-conscious about their chest protrusion, especially during sports or when changing in public.

The exact cause of the overgrowth of the costal cartilages that leads to pectus carinatum is unknown. It is believed to be a disorder of the cartilage growth plates. There is a strong genetic component, as the condition often runs in families, but the specific genes responsible have not been fully identified in most cases.

Clinically, it’s often due to abnormal growth of costal cartilage during adolescence, and in many cases, it’s idiopathic (without a known cause).

Pectus carinatum is a congenital deformity, meaning the predisposition is present at birth, even if the protrusion itself is not noticeable. It is not contagious and is not caused by any action or behavior.

• The deformity often becomes much more apparent and progresses significantly during the adolescent growth spurt, typically between the ages of 11 and 15, when the bones and cartilage are growing rapidly.
• Risk Factors:
  • Gender: It is significantly more common in boys than in girls, at a ratio of about 4 to 1.
  • Family History: Having a family member with a chest wall deformity increases the risk.
  • Associated Syndromes: While most cases are isolated, pectus carinatum can sometimes be a feature of certain genetic connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome, or other congenital conditions.

Clinically, there’s often a family history, and while it doesn’t usually cause symptoms, I screen for underlying syndromes when other physical signs are present.

The primary sign of the condition is its physical appearance.

The Physical Deformity

• A visible outward protrusion of the sternum and ribs.
• The chest may be symmetrical, with the center pushed out, or asymmetrical, with one side being more prominent than the other.

Physical Symptoms

In the vast majority of cases, pectus carinatum does not cause any physical symptoms. The heart and lungs are almost always completely normal and are not affected by the shape of the chest wall.

• In some instances of very severe deformity, an adolescent may experience some symptoms during intense aerobic exercise, such as:
  • Shortness of breath.
  • A decreased endurance compared to their peers.
  • Some may report tenderness or pain at the site of the protruding cartilage.

Psychosocial Symptoms

For most teenagers with pectus carinatum, the most significant symptoms are psychosocial. The appearance of their chest can be a source of considerable embarrassment and self-consciousness. This can lead to:

• Poor body image and low self-esteem.
• Avoidance of activities where the chest is exposed, such as swimming or changing in a locker room.
• A tendency to wear baggy clothing to hide the chest’s shape.
• Social anxiety and withdrawal.

It is this significant impact on a teenager’s emotional well-being and quality of life that is the primary reason for seeking treatment.

Clinically, I find that while function is usually preserved, the outward chest prominence is the main concern especially during puberty or growth spurts.

The diagnosis of pectus carinatum is made clinically, based entirely on a physical examination. A pediatrician, pediatric surgeon, or orthopedic specialist can diagnose the condition simply by observing the characteristic outward protrusion of the chest wall.

During the evaluation, the specialist will assess several key factors:

• Severity: They will measure the degree of the protrusion.
• Symmetry: They will note whether the deformity is symmetrical or asymmetrical.
• Flexibility: This is a crucial part of the exam. The doctor will gently push on the protruding sternum to assess the flexibility and pliability of the chest wall. This is the most important factor in determining whether the patient will be a good candidate for non-surgical bracing.

Are Imaging Tests Needed?

For a typical diagnosis of pectus carinatum, imaging tests are usually not necessary.

• A chest X-ray may be taken to get a lateral (side) view to see the angle of the sternum.
• A CT or MRI scan is not needed for diagnosis but may be performed as part of a pre-operative planning process if a patient is being considered for surgical correction.

In some cases, the doctor may order pulmonary function tests or an echocardiogram to check lung and heart function, but these are almost always found to be normal.

In my experience, I also evaluate for scoliosis, mitral valve prolapse, or other associated features if a connective tissue disorder is suspected.

The primary reason for treating pectus carinatum is to improve the cosmetic appearance of the chest and to address the psychosocial distress it causes. The good news is that modern treatment for this condition is highly effective.

1. Orthotic Bracing (Non-Surgical Treatment)

In recent years, custom-fitted dynamic compression bracing has revolutionized the treatment of pectus carinatum and is now considered the first-line therapy for most patients whose chests are still growing and flexible.

• How it Works: The principle is similar to how orthodontic braces work to straighten teeth. A lightweight, custom-molded brace is designed to apply constant, gentle pressure to the most prominent part of the chest. This pressure, applied over many months, gradually remodels the soft, pliable cartilage and encourages the sternum to move into a flatter, more normal position.
• The Process: A patient is fitted for the brace by a trained orthotist. The brace must be worn for many hours a day, often ranging from 14 to 23 hours. The duration of treatment depends on the severity and rigidity of the deformity but typically lasts from several months to over a year.
• Effectiveness: The best results are achieved when treatment is started during the adolescent growth spurt when the chest wall cartilage is most malleable. With good compliance (wearing the brace as prescribed), bracing is highly successful in correcting the deformity in the vast majority of appropriately selected patients.

2. Surgical Correction (The Ravitch Procedure)

Surgery is now considered a second-line option. It is typically reserved for patients with a very severe or rigid deformity that is not suitable for bracing, or for those who were not successful with a bracing regimen.

• The Procedure: The standard operation is called the Ravitch procedure. In this operation, a thoracic or pediatric surgeon makes a horizontal incision across the chest. The overgrown costal cartilages are surgically removed, allowing the sternum to be repositioned in a flatter orientation. In some cases, a temporary metal strut may be placed behind the sternum to hold it in its new position while the cartilage regrows and heals.
• Outcomes: The surgical results are generally excellent, but it is a major operation with a longer recovery time and a more significant scar compared to bracing.

3. Observation

For individuals with a very mild pectus carinatum that is not causing them any cosmetic or psychological concern, no treatment is necessary.

Clinically, surgery (such as the Ravitch procedure) is reserved for severe or unresponsive cases, but many patients achieve excellent results with conservative treatment.

Pectus carinatum, or “pigeon chest,” is a common congenital deformity of the chest wall that results from an overgrowth of cartilage, causing the breastbone to protrude outward. For the vast majority of individuals, it is a purely cosmetic condition that does not cause any harm to the heart or lungs. However, the emotional and psychological impact on a self-conscious teenager can be significant. It is important for families to know that this is a highly correctable condition. The development of non-surgical dynamic compression bracing has transformed care, offering a safe and highly effective way to gradually reshape the chest without the need for major surgery. For those with more severe or rigid deformities, the surgical Ravitch procedure remains an excellent option. In my experience, early recognition and consistent brace therapy often spare adolescents from surgery and help restore confidence in their appearance.

The American Pediatric Surgical Association (APSA). (n.d.). Pectus Carinatum. Retrieved from https://eapsa.org/parents/learn-about-a-condition/thoracic/pectus-carinatum/

The Mayo Clinic. (2022). Pectus carinatum. Retrieved from https://www.mayoclinic.org/diseases-conditions/pectus-carinatum/symptoms-causes/syc-20355490

Cincinnati Children’s Hospital Medical Center. (n.d.). Pectus Carinatum (Pigeon Chest). Retrieved from https://www.cincinnatichildrens.org/health/p/pectus-carinatum