A pulmonary embolism most commonly causes sharp chest pain on one side, typically the side where the clot has lodged in the lung. The pain tends to worsen when you take a deep breath, cough, or exert yourself. But chest pain isn’t the only possibility. Depending on the size and location of the clot, the pain can also show up in your back, shoulder, neck, upper abdomen, or even feel like a heart attack.
The Most Common Location: One-Sided Chest Pain
The hallmark pain of a pulmonary embolism is pleuritic chest pain, meaning pain tied to breathing. It’s usually sharp or stabbing rather than dull or aching, and it intensifies when you inhale deeply or change position. This happens because smaller clots travel to the outer edges of the lung’s blood vessels, cutting off blood flow to a section of lung tissue. That damaged tissue irritates the pleura, the thin membrane lining your lungs and chest wall, which is densely packed with nerve endings.
The pain typically stays on one side of the chest, corresponding to whichever lung is affected. It can feel localized to a specific spot rather than spread across the whole chest. Patients often rate the pain as severe. In one published case, a patient described it as 10 out of 10 on a pain scale.
That said, chest pain isn’t universal. Studies show that anywhere from 19% to 59% of people with a confirmed pulmonary embolism report chest pain. The wide range reflects differences in clot size, location, and individual pain perception. A large U.S. registry found that about 39% of confirmed cases involved chest pain, while a Chinese study put the number at roughly 35%. Many people experience shortness of breath as their primary or only symptom.
When the Pain Feels Like a Heart Attack
Large clots that lodge in the main pulmonary arteries near the center of the chest can produce a different kind of pain: heavy pressure or squeezing that mimics a heart attack. This happens because a large central clot forces the right side of the heart to work much harder against the blockage, starving the heart muscle of oxygen. The resulting pain can feel like tightness or heaviness behind the breastbone rather than the sharp, breath-linked pain of a smaller clot.
Distinguishing between a pulmonary embolism and a heart attack based on pain alone is unreliable. Both can cause acute chest pain, shortness of breath, and even fainting. Physical examination alone cannot reliably separate the two. This is one reason emergency departments rely on imaging and blood tests rather than pain descriptions to make the diagnosis.
Pain in the Back, Shoulder, and Neck
Pulmonary embolism pain doesn’t always stay in the chest. Back pain, particularly on one side, is a recognized presentation. In one documented case, a patient developed sharp left-sided back pain along with left shoulder pain 13 days after surgery, with no chest pain at all. The pain turned out to be from a pulmonary embolism.
Neck-to-shoulder pain is rarer but documented. The lungs share nerve pathways with the neck and shoulder region, so irritation from a clot in the lung can produce referred pain in these areas. One case report described a patient whose only pain symptom was a dull ache running from the right side of the neck down to the shoulder. Because the nerve signals from the lung converge with sensory nerves from the neck and shoulder area, the brain can misinterpret where the pain is actually coming from.
Cleveland Clinic lists unexplained sharp pain in the chest, arm, back, shoulder, neck, or jaw as potential signs, noting the pain can get worse when you breathe.
Upper Abdominal Pain
Abdominal pain is an uncommon but well-documented presentation. It typically shows up in the right upper quadrant, the area under your right ribs. In one case, a 53-year-old man came to the emergency department with worsening right upper quadrant pain and fevers. The pain had started in his lower right back and radiated forward to his abdomen. He was ultimately diagnosed with a pulmonary embolism.
The likely mechanism involves diaphragmatic pleurisy. The diaphragm sits directly below the lungs, and when a clot irritates the lower portion of the pleural lining near the diaphragm, the pain can be felt in the upper abdomen instead of the chest. This makes pulmonary embolism easy to mistake for gallbladder problems, liver issues, or other abdominal conditions.
What Makes the Pain Worse
The single most distinctive feature of pulmonary embolism pain is its relationship to breathing. Taking a deep breath, coughing, laughing, or any movement that expands the chest wall typically sharpens the pain. Physical exertion also worsens it, partly because faster, deeper breathing increases pleural irritation and partly because the heart is already strained by the blocked blood flow. Changing body position, particularly bending or twisting, can intensify the pain as well.
This breath-linked quality is what separates pleuritic pain from the constant, pressure-like pain of a heart attack, which generally doesn’t change with breathing. However, central pulmonary embolisms that strain the heart can produce steady pain that doesn’t follow this pattern, which is exactly why the condition is so easy to misdiagnose.
Leg Pain as a Warning Sign
Because most pulmonary embolisms originate from blood clots in the deep veins of the legs, pain or swelling in one leg can be an important accompanying clue. Deep vein thrombosis typically causes pain, swelling, redness, or weakness in the affected leg. When chest pain or unexplained shortness of breath occurs alongside leg symptoms, the combination is a strong signal that a clot may have traveled from the leg to the lungs.
Not everyone with a pulmonary embolism has noticeable leg symptoms. The original clot may have already fully detached and traveled to the lungs, leaving little evidence behind in the leg. But when both are present, the combination is one of the most recognizable patterns in emergency medicine. The Wells scoring system, a widely used clinical tool for assessing pulmonary embolism risk, assigns its highest point value (3 points) to visible signs of a deep vein clot.