Postural Alterations in Adolescents With Pectus Excavatum and Pectus Carinatum: A Retrospective Observational Study

Introduction

Pectus excavatum (PE) and pectus carinatum (PC) are the most common anterior chest wall deformities observed during childhood and adolescence, arising from abnormal morphologic development of the sternum and costal cartilages. Rather than isolated structural variations, they reflect disturbances in chest wall growth dynamics and connective tissue organization during periods of rapid somatic development. Although the precise etiopathogenesis remains unclear, current evidence supports a multifactorial origin involving disproportionate costal cartilage growth, intrinsic connective tissue fragility, and genetic susceptibility, often associated with familial clustering and systemic connective tissue disorders. Epidemiological data suggest that chest wall deformities occur in approximately 1% of the pediatric population and are more frequent in males [1–3].

Previously regarded as purely cosmetic conditions, the literature demonstrates that pectus deformities influence respiratory mechanics, thoracic rigidity, spinal alignment, musculoskeletal balance, and posture in multiple dimensions [4–6]. Several studies have reported that adolescents with PE or PC can present with increased thoracic kyphosis, forward shoulder posture, anterior head tilt, and reduced spinal mobility compared with healthy peers [4,5]. These findings show the biomechanical interdependence between chest wall morphology and spinal alignment.

Recent advances in conservative management have demonstrated favorable clinical outcomes. Dynamic compression orthoses for PC and vacuum bell therapy for PE are important non-operative treatment options that can be monitored using objective, radiation-free three-dimensional (3D) surface imaging. Serial external 3D scanning enables quantitative follow-up of deformity correction and supports individualized brace adjustment or vacuum bell use over time [7]. In addition to morphologic improvement, patients with untreated pectus deformities can experience impaired body image and reduced quality of life, highlighting the clinical relevance of effective conservative management within a comprehensive care framework [8]. Structured rehabilitation strategies have also been investigated for their potential to improve postural and respiratory function in children with PE [9]. Deformity severity can be objectively quantified using radiation-free 3D imaging techniques [10], and long-term follow-up studies indicate that conservative methods can reduce surgical needs in selected cases [9]. Pulmonary rehabilitation programs have also been reported to improve respiratory and postural outcomes in patients with PE [11].

The general epidemiology of postural disorders among adolescents indicates that thoracic kyphosis, scoliosis, shoulder asymmetry, and muscle imbalances occur more frequently than expected [6,12]. Lifestyle factors such as sedentary behavior and non-ergonomic postural habits further contribute to these alterations [6,12]. Consequently, children with structural deformities tend to have more pronounced postural adaptations.

However, studies systematically analyzing postural deviations in children with PE and PC remain limited. Therefore, this study aimed to identify the prevalence and patterns of postural alterations associated with pectus deformities, evaluate their relationship with deformity type and severity, and provide reference data to guide clinical assessment and therapeutic strategies.

Material and Methods

This retrospective descriptive study analyzed medical records of patients aged 10–18 years who were evaluated for chest wall deformities between 2018 and 2024 at a tertiary Pectus Clinic in Istanbul, Turkey. Ethics approval was obtained from the Nişantaşı University Medical Research Ethics Committee (Approval No: 2025-07/Date: 09.09.2025), and the study adhered to the principles of the Declaration of Helsinki.

The study included children and adolescents with a confirmed diagnosis of pectus excavatum (PE) or pectus carinatum (PC) based on clinical evaluation. Inclusion criteria were complete medical documentation and aged 10–18 years. Exclusion criteria were chronic systemic diseases, musculoskeletal disorders, genetic syndromes, significant orthopedic deformities, or psychiatric conditions that could affect posture. After applying these criteria, a total of 268 patients were included in the final analysis.

Demographic variables such as age, sex, height, weight, and body mass index (BMI) were recorded, along with deformity type (PE, PC, or mixed). Deformity severity (mild, moderate, severe) was determined according to standardized clinical severity criteria based on physical examination findings and deformity characteristics, as previously described [5,6]. Postural evaluation was performed during the initial standardized physical examination. Parameters recorded included forward head posture, rounded shoulders, shoulder height asymmetry, thoracic kyphosis, scoliosis, increased or flat lumbar lordosis, and anterior pelvic tilt. Overall posture was quantified using the New York Posture Rating Chart (NYPS), calculated according to standardized procedures.

Data analysis was performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed with the Shapiro-Wilk test. Normally distributed variables are expressed as mean±standard deviation (SD). Categorical variables are presented as frequencies and percentages. Group comparisons for categorical variables were performed using the chi-square (χ2) test. Statistical significance was set at P<0.05.

Results

DEMOGRAPHIC CHARACTERISTICS:

A total of 268 patients aged 10–18 years were included in the study, with a mean age of 15.6±1.7 years. Most participants were male (n=233; 86.9%). The mean height was 175.5±9.8 cm, mean weight was 60.6±10.3 kg, and mean body mass index (BMI) was 19.6±2.6 kg/m2 (Table 1). There was no significant difference between the PE and PC groups in terms of age, height, weight, or sex distribution (P>0.05). However, BMI was significantly higher in the PC group (P=0.027).

DISTRIBUTION OF DEFORMITY TYPE AND SEVERITY:

Among all patients, 166 (61.8%) had pectus excavatum (PE), 85 (31.8%) had pectus carinatum (PC), and 17 (6.4%) had a mixed deformity (MX). Deformity severity increased progressively with age (χ2=31.79; P<0.001), and the prevalence of severe deformity was highest among patients aged 16–18 years (Table 2).

POSTURAL FINDINGS:

Postural alterations were highly prevalent in both groups (Table 3). The most frequent findings were forward head posture (90.3%), rounded shoulders (81.7%), thoracic kyphosis (68.3%), and scoliosis (50.7%).

When compared by deformity type, PC patients exhibited significantly higher rates of thoracic kyphosis (92.1% vs 67.1%, P<0.001), scoliosis (80.2% vs 50.7%, P<0.001), shoulder asymmetry (80.2% vs 59.6%, P=0.001), and increased lumbar lordosis (72.3% vs 54.1%, P=0.006) compared with PE patients. Conversely, the prevalence of flat lumbar lordosis and anterior pelvic tilt was lower in the PE group, but the difference was not statistically significant (P>0.05).

POSTURAL DEFORMITIES BY AGE GROUP:

Postural alterations showed a gradual increase in frequency with age (Figure 1). In particular, thoracic kyphosis and shoulder asymmetry became more pronounced after the age of 15. The correlation between age and deformity severity was moderate and statistically significant (r=0.46, P<0.001).

Discussion

The present study confirms that postural alterations are highly prevalent among adolescents with PE and PC, supporting prior evidence that these deformities are associated with complex musculoskeletal adaptations rather than being purely cosmetic anomalies [1–3]. The prevalence of postural deviations in our cohort (nearly 90%) aligns closely with previously reported ranges of 80–90% among patients with anterior chest wall deformities [3,13]. These findings indicate that deviations in thoracic morphology can substantially affect sagittal and coronal balance, influencing both spinal alignment and shoulder position [4,13].

The male predominance observed in this study (86.9%) is consistent with epidemiological data showing that PE and PC occur 4–5 times more frequently in males than in females [2,6,7]. Likewise, the mean age of 15.6 years corresponds to the typical adolescent growth period during which deformities become more pronounced due to accelerated skeletal development [2,13]. Similar age-related progression in deformity severity has been noted in PE and PC populations, with increasing rigidity of the anterior chest wall leading to reduced flexibility and more visible asymmetry [5,6].

Regarding deformity distribution, PE was the most frequent subtype (61.8%), followed by PC (31.8%) and mixed forms (6.4%), paralleling previously published data that identify PE as the dominant anterior chest wall deformity in adolescents [3,6,13]. The observed positive correlation between deformity severity and postural deviation supports findings that thoracic distortion and musculoskeletal imbalance are biomechanically linked [9,10]. This interdependence between the thoracic cage and spinal posture has been emphasized by Mete et al [3,9], who demonstrated that changes in the chest wall contour can lead to compensatory thoracic kyphosis and scoliosis. Similarly, Koumbourlis [13] noted that rigidity of the chest wall can result in altered muscle tone and compensatory curvature, particularly in the upper thoracic region.

The higher rates of thoracic kyphosis, scoliosis, and shoulder asymmetry observed among PC patients in this study are consistent with the findings of Martinez-Ferro [6] and Altınok et al [7], who reported that anterior chest wall stiffness in PC contributes to compensatory spinal deviation. This mechanical imbalance underscores the necessity of early musculoskeletal evaluation and individualized management in pectus patients.

Recent advances in non-surgical treatment have provided encouraging results. Vacuum bell therapy for PE and dynamic compression bracing for PC have both demonstrated significant improvements in chest wall symmetry and, to a lesser extent, postural alignment [5,6,8,11,14]. Our results complement these observations, suggesting that early initiation of conservative management – before skeletal maturity – can improve esthetic and functional outcomes. Moreover, integrating postural rehabilitation strategies into conservative treatment protocols has been shown to enhance respiratory efficiency and spinal mobility [10,11].

Psychological and quality-of-life factors are also relevant to the clinical picture. Steinmann et al [12] demonstrated that even mild pectus deformities can negatively affect self-image and physical confidence, which can further influence posture and physical activity levels. Therefore, addressing postural and psychosocial factors together may improve both patient satisfaction and functional outcomes.

The strengths of the present study include a relatively large sample size, standardized clinical assessment, and the use of a validated posture evaluation tool (New York Posture Rating Chart). However, certain limitations should be noted. The cross-sectional design precludes causal interpretation, and radiological quantification of spinal curvature was not available for all participants. Furthermore, the absence of a control group limits generalizability, as highlighted in prior observational studies [1,2]. Future prospective studies incorporating 3D postural analysis and respiratory function assessment are warranted to better define the temporal relationship between chest wall deformities and musculoskeletal adaptation.

Conclusions

Adolescents with pectus excavatum and pectus carinatum exhibit a high prevalence of postural alterations that correlate with deformity type, severity, and age. The predominance among males and the progressive increase in deformity severity with age highlight the need for early recognition and clinical intervention. These findings demonstrate that pectus deformities extend beyond cosmetic concerns, affecting both thoracic mechanics and spinal alignment. Comprehensive assessment and the integration of posture-focused rehabilitation with non-surgical correction techniques may prevent further musculoskeletal imbalance and optimize functional as well as esthetic outcomes in this population.