What conditions are associated with a crawling or creeping sensation in the chest?

Crawling Sensation in the Chest: Differential Diagnosis and Clinical Approach

A crawling or creeping sensation in the chest is most commonly associated with anxiety disorders, panic attacks, and paresthesias from peripheral nerve irritation, though cardiac and esophageal causes must be systematically excluded first. 1

Immediate Life-Threatening Exclusions Required

Before attributing chest sensations to benign causes, you must rule out acute coronary syndrome, pulmonary embolism, and aortic dissection:

• Obtain a 12-lead ECG within 10 minutes to identify ST-elevation, ischemic changes, or arrhythmias that could manifest as unusual chest sensations 1
• Measure high-sensitivity cardiac troponin immediately because atypical presentations of myocardial injury can include paresthesias or "crawling" sensations rather than classic pressure 1
• Women, elderly patients, and those with diabetes frequently present with atypical symptoms including unusual sensations, tingling, or discomfort that does not fit classic angina patterns 1, 2

Primary Causes of Crawling Chest Sensations

1. Anxiety and Panic Disorder (Most Common)

Psychological and psychiatric conditions are present in approximately 52% of patients with non-cardiac chest pain and frequently manifest as unusual sensations including crawling, tingling, or paresthesias. 3

• Central nervous system–visceral interactions, hypervigilance, and sympathetic activation contribute to abnormal chest sensations in anxiety disorders 3
• Panic disorder produces chest discomfort accompanied by dyspnea, palpitations, diaphoresis, and paresthesias that patients often describe as "crawling" or "tingling" 1, 4
• Screen with a two-item questionnaire: "In the past month, have you been bothered by feeling nervous, anxious, or on edge?" and "In the past month, have you been unable to stop or control worrying?" 5

2. Peripheral Nerve Irritation and Radiculopathy

• Cervical radiculopathy can produce dermatomal pain and paresthesias radiating from the cervical spine to the chest wall, often described as crawling, tingling, or burning sensations 3
• Intercostal nerve irritation from muscle strain, rib subluxation, or thoracic spine pathology generates localized crawling sensations 3
• Herpes zoster produces dermatomal pain triggered by touch that patients describe as burning, tingling, or crawling before the characteristic rash appears 1, 4

3. Esophageal Hypersensitivity and Visceral Hyperalgesia

Functional chest pain reflects visceral hypersensitivity—abnormal perception of otherwise normal esophageal stimuli—and can manifest as crawling, tingling, or other unusual sensations. 3, 6

• Peripheral and/or central sensitization are responsible for reduced pain thresholds in patients with non-cardiac chest pain 6
• Esophageal dysmotility and spasm can produce unusual sensations including crawling or creeping discomfort 3, 7
• Gastroesophageal reflux disease may trigger abnormal sensory perception in the esophagus 8, 6

4. Musculoskeletal Causes

• Costochondritis and intercostal myofascial injury can produce localized crawling sensations, particularly when inflammation affects nerve endings in the chest wall 1, 3
• Pain reproducible with palpation, breathing, turning, or arm movement suggests musculoskeletal origin 1, 3

Diagnostic Algorithm

Step 1: Cardiac Exclusion (First 10 Minutes)

• Perform 12-lead ECG and measure high-sensitivity troponin 1
• If ECG shows ischemic changes or troponin is elevated, activate emergency protocols 1, 2
• If both are normal but cardiovascular risk factors exist, repeat troponin at 3–6 hours 1, 2

Step 2: Characterize the Sensation

• Duration and pattern: Fleeting sensations lasting seconds suggest non-cardiac etiology; gradual buildup over minutes suggests ischemia 1
• Triggers: Sensations provoked by anxiety, hyperventilation, or stress point to panic disorder 3, 5
• Distribution: Dermatomal pattern suggests radiculopathy or herpes zoster; diffuse chest wall suggests anxiety or musculoskeletal cause 1

Step 3: Physical Examination

• Palpate costochondral junctions for reproducible tenderness (costochondritis accounts for 43% of non-cardiac chest pain) 1, 3
• Assess for dermatomal sensory changes and check for early vesicular lesions of herpes zoster 1, 4
• Reproduce symptoms with chest wall movement or cervical spine range of motion 3

Step 4: Psychiatric Screening

• Use validated screening tools for anxiety and panic disorder when cardiac causes are excluded 5
• Depression, anxiety, and gastro-esophageal syndromes occur roughly ten-fold more often than coronary artery disease in low-risk chest-pain patients 3

Step 5: Esophageal Evaluation (If Indicated)

• Trial of high-dose proton-pump inhibitor therapy for suspected gastroesophageal reflux disease 3, 2
• If symptoms persist despite PPI therapy, perform pH-impedance monitoring and high-resolution manometry to detect visceral hypersensitivity or motility disorders 3

Critical Pitfalls to Avoid

• Do not dismiss cardiac causes based solely on unusual symptom descriptors; women and elderly patients frequently describe atypical sensations including crawling, tingling, or burning rather than classic pressure 1, 2
• Do not assume a normal physical examination excludes acute coronary syndrome; uncomplicated myocardial infarction can present with entirely normal findings 1, 4
• Psychological factors are common (≈52% prevalence) yet frequently under-recognized and under-referred (referral rate <10%); cognitive-behavioral therapy reduces chest-pain frequency by about 32% over three months 3
• Do not rely on nitroglycerin response to differentiate cardiac from esophageal causes, as esophageal spasm may also respond 3, 2

Management Based on Etiology

• Anxiety/panic disorder: Cognitive-behavioral therapy is first-line; consider selective serotonin reuptake inhibitors for persistent symptoms 3
• Costochondritis: NSAIDs (ibuprofen 600–800 mg three times daily for 1–2 weeks) and avoidance of aggravating movements 3
• Herpes zoster: Antiviral therapy within 72 hours of rash onset; consider gabapentin or pregabalin for neuropathic pain 1
• Esophageal hypersensitivity: Tricyclic antidepressants (e.g., imipramine 50 mg daily) or selective serotonin reuptake inhibitors to modulate visceral pain perception 6