Pulmonary embolism (PE) pain is most commonly felt in the chest, either under the breastbone or on one side. About 54% of PE patients experience chest pain, making it the single most reported symptom. But PE can also cause pain in less expected places, including the upper back, shoulder, neck, jaw, and even the upper abdomen.
Where Chest Pain Shows Up
The chest pain from a PE doesn’t always land in the same spot. It can occur directly behind the breastbone (substernal), which happens in roughly 15% of cases, or off to one side of the chest, which is more common at about 39% of cases. The side where you feel it often corresponds to where the blood clot has lodged in the lung. Because clots from the legs travel through the right side of the heart, the right lung is frequently affected, but clots can land in either lung or both.
The sensation varies. Many people describe it as sharp or stabbing, but it can also feel like burning, aching, or a dull heaviness. The hallmark feature is that it gets worse when you breathe in deeply, cough, or bend over. This type of breathing-related chest pain is called pleuritic pain, and it happens because the clot irritates the thin membrane lining the lungs. That membrane has nerve endings that fire when inflamed or stretched, which is why each deep breath intensifies the discomfort. Some people instinctively hunch forward or press their hands against their chest to limit how much their rib cage expands.
How It Differs From Heart Attack Pain
PE chest pain is often mistaken for a heart attack, and for good reason. Both can produce sharp or pressure-like pain in the center of the chest. The key difference is in what triggers it. Heart attack pain is typically constant, feels like squeezing or tightness, and doesn’t change much with breathing. PE pain sharpens noticeably when you inhale, cough, or shift position. Heart attack pain also commonly radiates down the left arm, while PE pain is more likely to stay in the chest or radiate to the back and shoulder.
That said, these patterns aren’t absolute. A large PE that strains the right side of the heart can produce constant, pressure-like chest pain that closely mimics a heart attack. The overlap is real enough that emergency physicians use scoring systems and imaging to distinguish between them rather than relying on pain description alone.
Pain Beyond the Chest
PE doesn’t always announce itself with classic chest pain. The clot’s irritation of the lung lining can send pain signals to areas that seem unrelated to the lungs.
- Shoulder and upper back: Referred pain to the shoulder or between the shoulder blades is an uncommon but documented PE presentation. In one reported case, a 70-year-old woman presented with severe left shoulder and back pain with no chest pain at all. The shoulder pain can be intense enough to prevent lying down or sleeping flat.
- Neck and jaw: Pain radiating to the neck or jaw has been reported, particularly in patients with limited mobility or spinal cord injuries.
- Upper abdomen: Abdominal pain, especially in the right upper quadrant, is a rare PE symptom. It likely results from irritation of the diaphragm, which sits between the lungs and the abdomen. In one case, a 53-year-old man presented with worsening right-sided abdominal pain that started in his lower back before wrapping around to the front. He was ultimately diagnosed with PE.
These atypical presentations are uncommon, but they matter because they can delay diagnosis. If pain in any of these areas comes on suddenly and is accompanied by shortness of breath or a racing heart, PE belongs on the list of possible causes.
Leg Pain as an Early Warning
Because most pulmonary emboli start as blood clots in the deep veins of the legs, leg pain often appears before or alongside chest symptoms. Deep vein thrombosis (DVT) typically causes pain, cramping, or soreness that starts in the calf. The affected leg may also swell, feel warm to the touch, or develop reddish discoloration.
Not everyone with a PE notices leg symptoms first. In many cases, a clot breaks free and reaches the lungs before it causes noticeable leg pain. But if you’re experiencing new calf pain or swelling along with any chest or breathing discomfort, the combination is a significant red flag.
When PE Causes No Pain at All
Nearly half of PE patients don’t report chest pain. Shortness of breath is equally common, showing up in about 50% of cases, and some people experience breathlessness as their only symptom. Small clots may produce no noticeable symptoms whatsoever. In fact, an estimated 30 to 50% of venous blood clot events are clinically silent, meaning they cause no symptoms and go undetected.
Other symptoms that can accompany or replace pain include a heart rate above 100 beats per minute, coughing (sometimes with blood), lightheadedness, and a sudden feeling of anxiety or dread. A PE large enough to significantly block blood flow can cause fainting or a sudden drop in blood pressure. The combination of sudden breathlessness, chest pain that worsens with breathing, and a fast heart rate is the classic triad, but any one of these appearing without an obvious explanation warrants urgent evaluation.