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Some people are born with a breastbone that sinks inward (a funnel chest) or pushes outward (a pigeon chest). It can affect confidence a great deal, and when severe it can press on the heart. Surgery reshapes the chest, either by placing a curved metal bar behind the breastbone or by reshaping the cartilage directly. Recovery is dominated by pain in the first weeks, and by protecting the repair for as long as the bar stays in.
The problem being fixed
Pectus excavatum (funnel chest) is a posterior depression of the sternum and adjacent costal cartilages, the commonest congenital chest wall deformity. Pectus carinatum (pigeon chest) is the anterior protrusion variant, often managed with bracing rather than surgery in a growing child. Both typically become apparent or progress during the adolescent growth spurt.
Severity is quantified on computed tomography or magnetic resonance imaging by the Haller index — transverse thoracic diameter divided by the narrowest anteroposterior diameter — with a value above 3.25 conventionally regarded as severe. The correction index is increasingly preferred as it is less influenced by overall chest shape.
The honest position on physiology is that most patients with pectus excavatum have normal or near-normal resting pulmonary function. Where impairment exists it is usually a mild restrictive pattern, and cardiac effects — right ventricular compression, reduced stroke volume at higher workloads, mitral valve prolapse — appear during exercise rather than at rest. Body image and psychosocial impact are the dominant indication in most series, and that is a legitimate one; overstating the respiratory case does patients no favours when expectations are set.
What the operations involve
| Nuss procedure | Ravitch procedure | |
|---|---|---|
| Approach | Minimally invasive. Two lateral incisions; a curved steel bar is passed behind the sternum thoracoscopically and rotated to elevate it | Open. Anterior incision, subperichondrial resection of deformed cartilage, sternal osteotomy, sometimes with a temporary support strut |
| Bar in situ | Typically 2–3 years, then removed at a second operation | Usually none, or a shorter-term strut |
| Best suited to | Symmetrical excavatum, flexible chest wall, adolescents | Asymmetrical or complex deformity, carinatum, older or rigid chest walls, revision |
| Dominant early problem | Severe pain from sustained chest wall tension | Pain plus a larger wound and greater cartilage disruption |
Bar displacement requiring reoperation is the characteristic Nuss complication, reported in a small percentage of cases and most likely in the first weeks. Multicentre data report low overall major complication rates with good anatomical outcomes.1
Pain is the clinical problem of the first fortnight
The Nuss bar holds the chest wall under continuous tension, and the pain is genuinely severe — often worse than a thoracotomy in a patient with no prior illness experience. Thoracic epidural, paravertebral catheters and intercostal cryoablation are all used, cryoablation increasingly so with reported reductions in opioid requirement and length of stay. Inadequate analgesia here does not just cause distress: it prevents deep breathing, prevents mobilisation and produces the atelectasis that follows. Escalating analgesia is a respiratory intervention in this population.
What the cardiopulmonary evidence shows
This is worth knowing precisely, because it is commonly overstated in both directions. Meta-analysis of cardiovascular function after repair found improvement in cardiac performance, most evident during exercise rather than at rest.2 Multicentre prospective data reported improved exercise pulmonary function after repair, while static resting spirometry changed little.1 Systematic reviews of cardiopulmonary exercise testing describe modest gains in oxygen pulse and work capacity post-operatively, with considerable heterogeneity.3
The clinically useful summary: expect measurable improvement in exercise physiology, not in resting spirometry, and expect the largest reported benefits in quality-of-life and body-image measures.4 Early post-operative spirometry usually worsens from pain and chest wall stiffness before improving over months.
Physiotherapy after pectus repair
First days
- Assess analgesia first, and escalate before treating. Nothing else works until this is right.
- Sustained maximal inspiration and incentive spirometry for the expected reduction in lung volumes — see Incentive Spirometry.
- Supported cough and early mobilisation. Log roll and sit up without pulling through the arms, as with a sternotomy.
- Posture from day one. These patients frequently arrive with a long-standing protective thoracic kyphosis and rounded shoulders, and the operation has just changed the shape they were compensating for.
Weeks to months, with the bar in place
- Avoid the movements that displace a bar: trunk rotation under load, heavy or asymmetrical lifting, and contact or collision sport. Local protocols vary; follow the operating surgeon's, and know that restriction typically runs for the life of the bar.
- Progressive posture and scapular work is the core of rehabilitation, alongside restoring thoracic extension and shoulder range.
- Aerobic reconditioning resumes early — walking, then cycling and running as pain allows.
- After bar removal (typically 2–3 years), a short second recovery follows and unrestricted activity usually resumes.
Role of the physiotherapist
Advocate for analgesia as the first respiratory intervention, not a comfort measure. Restore lung volume and mobility early, then spend the long middle phase on the posture and thoracic mobility that the deformity shaped over a decade — this is where physiotherapy adds most, and it is often the part that is neglected once the patient leaves hospital. Know the local bar precautions precisely and be able to explain them to an adolescent who feels well and wants to return to sport. Set expectations on the evidence: better exercise capacity and appearance, not a transformed spirogram.
Evidence summary
Framing. Pectus repair is major chest wall surgery in a predominantly young, otherwise healthy population, undertaken largely for appearance and psychosocial impact with a secondary exercise-physiological rationale. Physiotherapy priorities are consequently unusual: analgesia advocacy and volume restoration acutely, then a prolonged posture and thoracic mobility phase constrained by bar precautions.1,4
Evidence — outcomesMulticentre prospective data across Nuss and Ravitch repairs reported low major complication rates, good anatomical correction and improved pulmonary function on exercise testing with little change in static spirometry.1 Meta-analysis of cardiovascular function found post-operative improvement in cardiac performance, predominantly during exercise.2 Systematic review of cardiopulmonary exercise testing describes modest improvements in oxygen pulse and work capacity, with marked heterogeneity in protocols and populations.3 Quality-of-life and body-image instruments show the largest and most consistent gains.4
Evidence — analgesiaPain after Nuss repair is severe and sustained by continuous chest wall tension. Comparative studies of intercostal cryoablation against thoracic epidural report reduced opioid requirement and shorter length of stay, and it is increasingly adopted.5 Analgesic adequacy is the proximate determinant of deep breathing, cough and mobilisation in the first week.
Physiotherapy implicationsTreat analgesia as the first respiratory intervention and escalate rather than working around it. Anticipate an early fall in lung volumes and use sustained maximal inspiration and mobilisation. Apply sternotomy-style upper limb principles for bed transfers. Prioritise thoracic extension, scapular control and posture through the months the bar is in situ, and follow the operating surgeon's precautions on rotation, lifting and contact sport. Counsel on the evidence: exercise capacity and appearance improve; resting spirometry largely does not.
Evidence gapsNo randomised trial compares Nuss with Ravitch repair, and no study has examined physiotherapy content, dose or timing after either. Bar precaution protocols are institutional convention rather than evidence-based, and the duration of activity restriction has never been tested. Long-term musculoskeletal outcomes after cartilage resection, and whether structured posture rehabilitation alters them, are undescribed.
References & evidence base
- Kelly RE Jr, Mellins RB, Shamberger RC, et al. Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 2013;217(6):1080–1089.
- Malek MH, Berger DE, Housh TJ, Marelich WD, Coburn JW, Beck TW. Cardiovascular function following surgical repair of pectus excavatum: a metaanalysis. Chest 2006;130(2):506–516.
- Maagaard M, Heiberg J. Improved cardiac function and exercise capacity following correction of pectus excavatum: a review of current literature. Ann Cardiothorac Surg 2016;5(5):485–492.
- Kelly RE Jr, Cash TF, Shamberger RC, et al. Surgical repair of pectus excavatum markedly improves body image and perceived ability for physical activity: multicenter study. Pediatrics 2008;122(6):1218–1222.
- Graves CE, Moyer J, Zobel MJ, et al. Intraoperative intercostal nerve cryoablation during the Nuss procedure reduces length of stay and opioid requirement: a randomized clinical trial. J Pediatr Surg 2019;54(11):2250–2256.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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