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1 · SNAPSHOT

Cardiac / Pulmonary Referred Pain (Visceral Mimic) body chart — Illustrative, not diagnostic. Canva body chart for Cardiac / Pulmonary Referred Pain (Visceral Mimic).

Who: Anyone with chest, upper back, shoulder or jaw pain. Including — especially — someone already discharged from an emergency department.
What: A visceral cause presenting as a musculoskeletal one.
How it behaves: Central or left chest ache ± neck, jaw, arm or back. Poor link to movement or posture. Associated: breathlessness, sweating, nausea, dizziness. Flags: night or rest pain, exertional onset, recent illness or immobility.

The one thing to take from this page:

"Not movement-provoked = not MSK until proven otherwise."

The one question, and the two branches

Can you reproduce the pain with movement or palpation?
YES	Probably musculoskeletal — but tenderness lowers probability, it does not exclude. Screen anyway.
NO	NOT MSK UNTIL PROVEN OTHERWISE. Vitals. Document your reasoning. Refer.

Exertional → cardiac. Pleuritic + short of breath → pulmonary. Record the vitals before you refer.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

On this pattern the subjective is not 70% — it is essentially all of it. Five stages, and the special questions are the point.

MAIN PROBLEM

"There's a heaviness across my chest."
"It comes on when I walk up the hill and goes when I stop."
"I can't get a full breath."

BODY CHART

Central or left chest, often diffuse — a hand, not a finger.
Mark the neck, jaw, both arms and the interscapular region. Referral to jaw or arm changes everything.
Mark the calf. Yes, on a chest pain history.

BEHAVIOUR — this is where it declares itself

	Visceral pattern	Musculoskeletal pattern
Movement	No consistent link	Reproducible
Position	Doesn't change it	Changes it
Exertion	Brings it on, rest eases it	Usually load-related, not exertion-related
Palpation	Doesn't reproduce it	Often reproduces it
Breath	Pleuritic → pulmonary	Rib and joint patterns also catch with breath — so use the whole picture
Onset	Often abrupt, or with illness	Often an event or a load

HISTORY

Cardiac risk — age, hypertension, cholesterol, diabetes, smoking, family history, previous events.
Recent immobility, long travel, surgery, plaster, pregnancy or postpartum, oestrogen-containing medication, known clotting disorder, active cancer.
Recent respiratory illness.
Have they already been assessed for this? Where, when, and what were they told? Being discharged from an emergency department is not clearance for a new or changed symptom.

SPECIAL / SCREENING QUESTIONS — never skipped, on any chest, upper back, jaw or shoulder presentation

Any breathlessness, sweating, nausea, light-headedness?
Does exertion bring it on and rest settle it?
Any calf pain or swelling?
Any fever, cough, coloured sputum, blood?
Any pain at night or at rest that doesn't change with position?
Have you fainted, or come close?

Assessing this region? Download the Thoracic Spine assessment template →

3 · HYPOTHESIS RANKING

On this page the ranking runs the other way. You are not ranking towards a diagnosis — you are ranking what you must not miss.

What you must not miss	The feature that raises it
Acute coronary syndrome	Exertional onset settling with rest, central heaviness, radiation to jaw or arm, sweating, nausea. Presentations vary — complex and atypical ones are described [1][2].
Pulmonary embolus	Pleuritic pain with breathlessness, calf symptoms, recent immobility, surgery, pregnancy or cancer.
Pneumonia or pleurisy	Fever, cough, coloured sputum, pleuritic pain.
Pneumothorax	Sudden breathlessness with sharp pleuritic pain, tall thin young adult or known lung disease.
Aortic pathology	Sudden severe tearing pain, front to back, unequal pulses.
Oesophageal and gastric causes	Relationship to meals, lying flat, reflux history.
Gallbladder and hepatobiliary	Right upper quadrant and right shoulder tip, relationship to food.
Herpes zoster	Dermatomal band, pre-eruptive pain, then rash.
Malignancy	Night pain, weight loss, smoking history, known cancer.

And then the musculoskeletal patterns

Only after the above. Costochondritis · thoracic PIV joint · costovertebral and costotransverse · rib injury · cervical and shoulder girdle referral.

Note what this means: musculoskeletal chest pain is common, including in emergency department presentations [3][4]. Most chest pain isn't cardiac — and you still screen every time, because the cost of the two errors is not symmetrical.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. On this page the whole thing is.

Finding	What it suggests	What you do
Central or crushing chest pain with breathlessness, sweating, nausea, or radiation to jaw or arm	Acute coronary syndrome	000. NOW.
Exertional onset settling with rest	Cardiac until proven otherwise	Same-day medical assessment
Sudden breathlessness with pleuritic pain, ± calf symptoms, immobility, surgery, pregnancy, cancer	Pulmonary embolus	EMERGENCY
Sudden severe tearing pain front to back, unequal pulses	Aortic dissection	000
Sudden pleuritic pain with breathlessness in a tall young adult or known lung disease	Pneumothorax	EMERGENCY
Fever, productive or bloody cough, hypoxia	Pneumonia, infection	Urgent medical review
Syncope or presyncope with chest pain	Cardiac or PE	EMERGENCY
Abnormal vital signs of any kind	Whatever the cause	Medical review
Pain not reproduced by any movement, position or palpation	Not musculoskeletal	Medical review — this is the whole rule
Night or rest pain unchanged by position	Visceral, infective, malignant	Medical review

What to do, in order

Stop. Don't treat.
Sit them down. Take the vitals — heart rate, blood pressure, respiratory rate, oxygen saturation if you have a probe, temperature.
Decide the tier: 000 · same-day emergency department · same-day GP · routine medical review.
Write your reasoning down — the features present, the features absent, the vitals, and what you're asking to be excluded.
Communicate it. Ring if it's urgent. Don't rely on the patient to relay it.
Do not start musculoskeletal treatment while you wait.

Cross-links: Referred pain — visceral · Costochondritis / Tietze's · Thoracic facet (PIV) joint dysfunction · Rib contusion / stress injury

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline for this presentation as a physiotherapy screening task.

The Australian anchor for the cardiac arm is the NHFA/CSANZ Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (Brieger et al. 2025, PMID 40180468), which the ACSQHC ACS Clinical Care Standard uses as its evidence base. The pulmonary embolism arm has the THANZ VTE guideline (Tran et al. 2019, PMID 30739331), which excludes VTE with a clinical prediction rule plus D-dimer and confirms it with imaging. Otherwise anchored to the emergency and primary-care literature on chest pain evaluation — acute coronary syndrome presentation and diagnostic evaluation (Barstow et al. 2020, PMID 32150364), contemporary approaches to pulmonary embolism diagnosis (Teissandier et al. 2024, PMID 38368878) and pulmonary embolism diagnosis and the D-dilemma (Horner et al. 2025, PMID 40360228) — with the Australasian prevalence work on musculoskeletal chest pain in emergency department presentations (Dacombe-Bird et al. 2024, PMID 38030390) and on reducing imaging for pulmonary embolism (Furyk et al. 2020, PMID 32023003).

PubMed Source

None of this is a physiotherapy guideline and none of it tells you what to do in a clinic room. It is the medical literature about the thing you are screening for. Your task on this page is recognition and referral, not diagnosis — and nothing here replaces sending someone for medical assessment.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2025Daas et al. (2025). A case report of complex acute coronary syndrome presentation: Plaque rupture and mild coronary artery ectasia presenting as de Winter T-waves morphing into anterior ST-elevation myocardial infarction in a young adult male. SAGE open medical case reports, 13, 2050313X251331733. https://doi.org/10.1177/2050313X251331733
2021Laher et al. (2021). Clinical Profile of Acute Coronary Syndrome Presentation to the Ladysmith Provincial Hospital: High Prevalence Among the Minority Indian Population. Cureus, 13(9), e17670. https://doi.org/10.7759/cureus.17670
2024Dacombe-Bird et al. (2024). Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review. Emergency medicine Australasia : EMA, 36(2), 302-309. https://doi.org/10.1111/1742-6723.14352
2021Mandrekar et al. (2021). Prevalence of musculoskeletal chest pain in the emergency department: a systematic review and meta-analysis. Scandinavian journal of pain, 21(3), 434-444. https://doi.org/10.1515/sjpain-2020-0168
2025Horner & Roberts (2025). Pulmonary embolism diagnosis and the D-dilemma. Emergency medicine journal : EMJ, 42(8), 560-561. https://doi.org/10.1136/emermed-2025-215058
2024Teissandier et al. (2024). Contemporary approaches to pulmonary embolism diagnosis: a clinical review. Clinical and experimental emergency medicine, 11(2), 127-135. https://doi.org/10.15441/ceem.23.157
2023Khandait et al. (2023). Acute pulmonary embolism: Diagnosis and management. Indian heart journal, 75(5), 335-342. https://doi.org/10.1016/j.ihj.2023.05.007
2026Ádám et al. (2026). [Development of a novel clinical prediction model for musculoskeletal chest pain in the emergency department]. Orvosi hetilap, 167(5), 180-187. https://doi.org/10.1556/650.2026.33484
2020Richardson et al. (2020). Predictors of Overtesting in Pulmonary Embolism Diagnosis. Academic radiology, 27(3), 404-408. https://doi.org/10.1016/j.acra.2019.04.018
2020Furyk & Banks (2020). Reducing imaging for pulmonary embolism diagnosis. Emergency medicine Australasia : EMA, 32(1), 176-178. https://doi.org/10.1111/1742-6723.13459
2022Aghajani et al. (2022). Predictors and mortality of patients with delayed pulmonary embolism diagnosis: A cohort study. Caspian journal of internal medicine, 13(4), 757-764. https://doi.org/10.22088/cjim.13.4.757
2016Bach et al. (2016). Timing of pulmonary embolism diagnosis in the emergency department. Thrombosis research, 137, 53-57. https://doi.org/10.1016/j.thromres.2015.11.019
2012Stochkendahl et al. (2012). A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up. Journal of manipulative and physiological therapeutics, 35(4), 254-62. https://doi.org/10.1016/j.jmpt.2012.04.003
2008Stochkendahl et al. (2008). Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial. BMC musculoskeletal disorders, 9, 40. https://doi.org/10.1186/1471-2474-9-40
2016Stochkendahl et al. (2016). Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain. Open heart, 3(1), e000334. https://doi.org/10.1136/openhrt-2015-000334
2017Gelfman (2017). Osteopathic Manipulation in Treatment of Musculoskeletal Chest Pain. The American journal of medicine, 130(6), 618. https://doi.org/10.1016/j.amjmed.2016.11.046
2013Ayloo et al. (2013). Evaluation and treatment of musculoskeletal chest pain. Primary care, 40(4), 863-87, viii. https://doi.org/10.1016/j.pop.2013.08.007
2020Liti et al. (2020). Clinical effectiveness of an outpatient pathway for low-risk chest pain emergency department visits. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, 27(4), 1341-1348. https://doi.org/10.1007/s12350-019-01814-9
2020Barstow (2020). Acute Coronary Syndrome: Presentation and Diagnostic Evaluation. FP essentials, 490, 11-19. PubMed 32150364
2024Gottlieb et al. (2024). Epidemiology of pulmonary embolism diagnosis and management among United States emergency departments over an eight-year period. The American journal of emergency medicine, 85, 158-162. https://doi.org/10.1016/j.ajem.2024.09.016

Mapped to this pattern

Wells PE
Wells Criteria for Pulmonary Embolism
PE pre-test probability · 7 items · 3 min

Generic measures that also apply

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