Can pulmonary embolism (PE) cause upper limb pain?

From the Guidelines

Pulmonary embolism typically does not cause upper limb pain as a primary symptom. Pulmonary embolism occurs when a blood clot lodges in the arteries of the lungs, causing symptoms that primarily affect the chest and respiratory system, such as sudden shortness of breath, chest pain that worsens with deep breathing, rapid heartbeat, and coughing (sometimes with blood) 1. Arm pain is not a characteristic symptom of pulmonary embolism itself. However, in rare cases, if a pulmonary embolism is very severe and leads to significant cardiac strain or reduced oxygen levels, a person might experience referred pain or discomfort in other areas of the body, including the arms.

Key Considerations

• The prevalence of pulmonary embolism (PE) varies depending on the clinical presentation, with estimated prevalences of ≤5%, 20%, and ≥50% for low, intermediate, and high probability patients, respectively 1.
• Diagnostic tests for venous thromboembolism (VTE), including PE, are subject to error and their accuracy depends on the prevalence of VTE in the population 1.
• The optimal diagnostic strategy for PE should balance the risk of false-negative and false-positive results, considering patients' and physicians' values and preferences, risk associated with different tests, cost, and feasibility 1.

Clinical Implications

• Anyone experiencing unexplained shortness of breath, chest pain, or other concerning symptoms should seek immediate medical attention, as pulmonary embolism can be life-threatening and requires prompt diagnosis and treatment.
• While arm pain is not a typical symptom of PE, it may be related to the original clot if the pulmonary embolism originated from a deep vein thrombosis (DVT) in the arm, which is much less common than leg DVTs.
• Clinicians should prioritize the diagnosis and treatment of PE based on the most recent and highest quality evidence, such as the American Society of Hematology 2018 guidelines for management of venous thromboembolism 1.

From the Research

Presentation of Pulmonary Embolism

• Pulmonary embolism (PE) is a life-threatening complication that can present with various symptoms, including chest pain and dyspnea 2, 3.
• Atypical presentations of PE can make diagnosis challenging, and these may include symptoms such as shoulder and back pain 4.
• The absence of typical symptoms like pleuritic chest pain, dyspnea, tachycardia, or symptoms of deep vein thrombosis can further complicate diagnosis 4.

Upper Limb Pain as a Symptom

• There is evidence to suggest that PE can present with upper limb pain, specifically shoulder pain, as an atypical symptom 4.
• A case report described a patient who presented with left shoulder and left-sided pleuritic back pain, and was subsequently diagnosed with a left-sided PE 4.
• While upper limb pain is not a typical symptom of PE, it is essential to consider PE in the differential diagnosis of patients presenting with unexplained upper limb pain, especially if they have risk factors for PE 4, 5.

Importance of Diagnosis

• PE is a potentially life-threatening condition, and prompt diagnosis is crucial to prevent morbidity and mortality 6, 2, 3, 5.
• Clinicians should be aware of the various presentations of PE, including atypical symptoms like upper limb pain, to ensure timely diagnosis and treatment 4, 3.