Shoulder injury related to vaccine administration (SIRVA)

Shoulder Injury Related to Vaccine Administration (SIRVA) Following COVID-19 Vaccination: Correlating MRI Findings with Patient Demographics

OBJECTIVES

Shoulder injury related to vaccine administration (SIRVA), previously observed with influenza vaccines, has gained clinical significance with widespread COVID-19 vaccination. However, few studies correlate vaccine types and demographic factors with the MRI findings of SIRVA. This study aimed to evaluate MRI findings of SIRVA following COVID-19 vaccination and assess associations with vaccine type and patient characteristics.

METHODS

A retrospective cohort study was conducted on 35 patients with new-onset shoulder complaints within six weeks of COVID-19 vaccination between May 2021 and May 2022. MRI findings suggestive of SIRVA were reviewed, including subacromial bursitis, rotator cuff tears, and adhesive capsulitis. Demographic data, vaccine type, clinical symptoms, and treatments were collected. Follow-up interviews (1-30 September 2024) assessed symptom persistence and vaccine hesitancy. Descriptive statistics and Chi-square tests were used to explore associations.

RESULTS

Of the 35 patients (mean age 53.6 ± 9.0 years; 54.3% female), subacromial bursitis was the most common MRI finding (89.5%), followed by tendonitis (47.4%) and adhesive capsulitis (36.8%). Tendonitis correlated with older age (p = 0.024) and AstraZeneca vaccination (p = 0.033). Subacromial bursitis was linked to female sex (p = 0.013) and higher BMI (p = 0.023). Adhesive capsulitis was associated with receiving the Sinopharm vaccine (p = 0.029). Persistent symptoms (22.9%) were more common in younger patients, women, and those with right-sided injections.

CONCLUSIONS

SIRVA following COVID-19 vaccination showed different MRI patterns associated with female sex, higher BMI, and vaccine type. Awareness of these patterns may expedite recognition of COVID-19-associated SIRVA in routine practice.

Comparison of Phenotypes of Headaches After COVID-19 Vaccinations Differentiated According to the Vaccine Used

Background/Objectives: In this ongoing, multicenter, global cohort observational study, phenotypes of headaches after COVID-19 vaccination were directly compared between different vaccines. Methods: Phenotypes of postvaccinal headache were recorded in 18,544 participants. The study was launched immediately after the start of the global COVID-19 vaccination campaign on 12 January 2021 and continued until 1 August 2023. Specific aspects of headaches and related variables were collected via an online questionnaire. The clinical headache characteristics of patients vaccinated with the Comirnaty (BioNTech), Jcovden (Johnson & Johnson), Sputnik V (Gamelaya), Covilo (Sinopharm), Spikevax (Moderna), Vaxzevria (AstraZeneca), and Convidecia (CanSino Biologics) vaccines were investigated. Results: Across all vaccines, the median and mean latency of headache onset after vaccine administration were 12 h and 23.3 h, respectively. The median and mean headache duration were 12 h and 23.3 h, respectively. When the nonreplicating viral vector vaccine Sputnik V was used, headaches occurred the fastest, with a latency of 17 h. The latencies for the Vaxzevria and Convidecia nonreplicating viral vector vaccines were 14.9 h and 19.1 h, respectively. The Covilo inactivated whole-virus vaccine had a latency of 20.5 h. The latencies of the mRNA-based Comirnaty and Spikevax vaccines were 26.0 h and 22.02 h, respectively. Analysis of variance revealed no significant differences in the mean duration of postvaccinal headache for the vaccines tested. Compared with the Comirnaty, Covilo, and Vaxzevria vaccines, the Spikevax vaccine induced significantly greater headache intensities. Vaxzevria was associated with a significantly higher frequency of concomitant symptoms than the other vaccines. Conclusions: The phenotype of postvaccinal headache can vary significantly between vaccines. These results have clinical implications for differentiating between postvaccinal headache and other primary and secondary headaches. This knowledge is clinically relevant in differentiating life-threatening vaccination complications, such as thrombotic syndromes, which are also associated with headaches. Based on these results, new diagnostic criteria for postvaccinal headaches can be developed.

An analysis of reported cases shoulder injury related to vaccine administration of after COVID-19 vaccination

To prevent COVID-19, the COVID-19 vaccine has been widely administered worldwide, but various complications accompany this vaccine. The aim of this study was to investigate the demographic patterns, clinical features, diagnostic findings, and treatment outcomes associated with shoulder injury related to vaccine administration (SIRVA). This study examined 22 patients with SIRVA following COVID-19 vaccination from the Web of Science (WOS) and PubMed databases. The patients were categorized based on sex, age, type of COVID-19 vaccine received, dose administered, latency of symptom onset, and the presence of specific clinical manifestations. Patients, evenly distributed by sex (12 females, 10 males), and aged 21 to 84 years (mean age 46.6), were analyzed. SIRVA cases were reported across all age groups. The Pfizer - BioNTech COVID-19 vaccine had the highest incidence (n = 8), followed by the Oxford/AstraZeneca COVID-19 vaccine (n = 4). Symptoms, primarily shoulder pain (n = 22) and shoulder mobility disorders (n = 18), occurred within three days post-vaccination. Some patients also reported shoulder swelling (n = 5) and fever (n = 2). Imaging revealed nonspecific X-ray findings, supraspinatus tendon calcification (n = 2), and shoulder edema and inflammation on MRI (n = 12). This study provides insights into the clinical aspects of SIRVA related to COVID-19 vaccination. Recognition and appropriate management of these complications are crucial for optimal patient outcomes.

Influenza vaccine related periostitis: A case report of a rare complication

As social distancing guidelines continue to diminish across the country, viral pathogens that were once absent during the COVID-19 pandemic, such as influenza and RSV, have once again become prominent. Although serious side effects of vaccinations are rare, local complications of bursitis and skin and soft tissue infections are well-documented in the literature. We present a case of 1 such rare side effect: influenza vaccine related periostitis. A 39-year-old male patient presented with left shoulder pain which developed 2 days after an influenza vaccination administered to the left deltoid. His symptoms were persistent despite rest and 1 week trial of NSAIDs. MRI imaging demonstrated marrow edema and a periosteal reaction of the left shoulder. Overall, vaccine induced periostitis is poorly documented in the literature and the pathophysiology has not been fully characterized. Further research is crucial to identify patient specific risk factors and to raise awareness of this rare complication to promote swift diagnosis and effective treatment.

Adhesive Capsulitis Following Improper Tetanus-Diphtheria (Td) Booster Administration

Adhesive capsulitis following vaccination is a rare complication secondary to improper intramuscular (IM) deltoid vaccine administration. It is considered a subset of the broad category known as shoulder injury related to vaccine administration (SIRVA). SIRVA typically results from improper shoulder anatomic localization prior to injection, leading to erroneous placement of the needle into the glenohumeral joint capsule or subacromial space. This can trigger a wide array of pathologies, including adhesive capsulitis. We present the first known case of adhesive capsulitis following improper tetanus-diphtheria (Td) vaccine administration. The patient, a previously healthy middle-aged female, began experiencing significant anterior left shoulder pain the day following a Td booster vaccination. She remarked receiving the injection "higher up" in the shoulder than normal. Over the next two weeks, she began noting significant shoulder stiffness, which was followed by a progressive loss of shoulder range of motion. Her symptoms persisted for four months without definitive diagnosis or treatment. After four months of symptoms, the patient visited an outpatient sports medicine clinic where the diagnosis of adhesive capsulitis was made. Although the patient was referred for physical therapy, focusing on gentle range of motion (ROM) and stretches, followed by a planned isometric strengthening program once ROM improved, she was eventually lost to follow-up, and her recovery is unclear. Given the rarity of the diagnosis, it is unclear if adhesive capsulitis, secondary to improper IM vaccination, follows the same temporal course as "classic" adhesive capsulitis or results in a different timeframe of recovery. Further studies are needed on this subject.

Frozen shoulder after COVID-19 vaccination versus idiopathic frozen shoulder: similar clinical features and functional improvement at 1-year follow-up

Background

Frozen shoulder after COVID-19 vaccination is sparsely discussed in the medical literature. We aimed to evaluate: (1) the differences in the baseline clinical features and functional outcomes of conservatively treated frozen shoulder following COVID-19 vaccination compared to idiopathic frozen shoulder (2) the improvements in pain scores, functional outcomes, and range of motion (ROM) at 6-10 months and at 1 year of follow-up in patients with frozen shoulder after COVID-19 vaccination treated by conservative therapy.

Methods

Between June 2021 and December 2021, 12 patients (13 shoulders) that were diagnosed with frozen shoulder after COVID-19 vaccination (vaccine related frozen shoulder [VRF] group) (final follow-up of 12.4 months ± 0.8 months) were compared with 20 patients that were diagnosed as idiopathic frozen shoulder unrelated to vaccination (unvaccinated frozen shoulder [UFS] group) (average follow-up of 13.4 ± 3.1 months). All patients were treated with home-based stretching exercises. Four (33%) patients in the VRF group and 15 (75%) patients in the UFS group underwent steroid injection in the suprascapular notch by an experienced radiologist.

Results

The left side was affected more frequently in the VRF group [n = 10 (83.3%)] than in the UFS group [n = 8 (40%), P = .03]. The VRF and the UFS groups were similar in the rest of the baseline clinical features, such as the age distribution, men/women ratio, baseline Oxford Shoulder Scores (OSS), ROM deficit, and pain visual analogue scale (VAS) scores. The OSS, VAS pain scores, and the ROM deficit significantly improved in the VRF group at the 6-10-month follow-up and then at the final (12.4 ± 0.8 months) follow-up compared to the baseline values. At the final follow-up, there were no significant differences in the average external rotation, external rotation deficit, elevation, elevation deficit, internal rotation, pain VAS scores, and OSS between the VRF and the UFS group.

Conclusion

To conclude, frozen shoulder following COVID-19 vaccination may present with clinical features similar to those of the idiopathic frozen shoulder. Furthermore, the patients with frozen shoulder following COVID-19 vaccination may continue to improve over one year with conservative treatment; the final improvements in function and ROM are similar to those with idiopathic frozen shoulder.

Contralateral second dose improves antibody responses to a 2-dose mRNA vaccination regimen

BACKGROUNDVaccination is typically administered without regard to site of prior vaccination, but this factor may substantially affect downstream immune responses.METHODSWe assessed serological responses to initial COVID-19 vaccination in baseline seronegative adults who received second-dose boosters in the ipsilateral or contralateral arm relative to initial vaccination. We measured serum SARS-CoV-2 spike-specific Ig, receptor-binding domain-specific (RBD-specific) IgG, SARS-CoV-2 nucleocapsid-specific IgG, and neutralizing antibody titers against SARS-CoV-2.D614G (early strain) and SARS-CoV-2.B.1.1.529 (Omicron) at approximately 0.6, 8, and 14 months after boosting.RESULTSIn 947 individuals, contralateral boosting was associated with higher spike-specific serum Ig, and this effect increased over time, from a 1.1-fold to a 1.4-fold increase by 14 months (P < 0.001). A similar pattern was seen for RBD-specific IgG. Among 54 pairs matched for age, sex, and relevant time intervals, arm groups had similar antibody levels at study visit 2 (W2), but contralateral boosting resulted in significantly higher binding and neutralizing antibody titers at W3 and W4, with progressive increase over time, ranging from 1.3-fold (total Ig, P = 0.007) to 4.0-fold (pseudovirus neutralization to B.1.1.529, P < 0.001).CONCLUSIONSIn previously unexposed adults receiving an initial vaccine series with the BNT162b2 mRNA COVID-19 vaccine, contralateral boosting substantially increases antibody magnitude and breadth at times beyond 3 weeks after vaccination. This effect should be considered during arm selection in the context of multidose vaccine regimens.FUNDINGM.J. Murdock Charitable Trust, OHSU Foundation, NIH.

Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review

BACKGROUND

The pathogenesis of shoulder injury related to vaccine administration (SIRVA) is incompletely understood, but it is postulated to be an immune-mediated inflammatory response to a vaccine antigen, leading to shoulder pain and dysfunction. The purpose of this investigation is to systematically review the literature related to SIRVA specifically after the COVID-19 vaccination by describing the diagnostic and clinical characteristics, diagnoses associated with SIRVA, and incidence between vaccine types.

METHODS

A systematic review was performed to identify level I to IV studies and case descriptions of shoulder pain occurring after COVID-19 vaccination. To confirm that no studies were missing from the systematic review, references of studies from the initial search were scanned for additional relevant studies.

RESULTS

A total of 22 studies, comprised of 81 patients, were identified meeting the inclusion/exclusion criteria. Reports were most commonly published from countries in Asia (53.1%; n = 43/81). The most commonly described vaccines were Oxford-AstraZeneca at 37.0% (n = 30/81) and Pfizer-BioNTech at 33.3% (n = 27/81). Symptoms occurred most commonly after at least 72 hours of administration (30.9%, n = 25/81). One hundred percent of patients (n = 81/81) described pain as an associated symptom and 90.1% of patients (n = 73/81) described multiple symptoms. The diagnostic modalities utilized to identify a specific pathology consisted of magnetic resonance imaging (55.6%; n = 45/81), ultrasound (28.4; n = 23/81), radiograph (25.9%; n = 21/81), and computed tomography (4.9%; 4/81). Nearly a third of patients (32.1%; n = 26/81) were diagnosed with bursitis, while 22 (27.2%) were diagnosed with adhesive capsulitis, 17 (21.0%) with either rotator cuff tear or tendinopathy, and 14 (17.3%) with polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. The 2 most common treatment options were physical therapy (34.6%; n = 28/81) and nonsteroidal anti-inflammatory medications (33.3%; 27/81). The majority of SIRVA cases (52.1%; n = 38/73) completely resolved within a few weeks to months.

CONCLUSION

Despite the limited quality and lack of large-scale studies, it is important for providers to recognize SIRVA as a potential risk factor as the number of patients receiving COVID-19 vaccinations and boosters continues to rise.

Analysis of patients with adhesive capsulitis after COVID-19 vaccination: An observational study

Objectives

This study aimed to increase the awareness of clinicians about shoulder injury related to vaccine administration (SIRVA) by analyzing 21 patients with adhesive capsulitis that developed after COVID-19 (coronavirus disease 2019) vaccination.

Patients and methods

In this observational study, 21 patients (11 males, 10 females; mean age: 60.7±7.3 years; range, 45 to 70 years) with incipient shoulder pain and limitation diagnosed with adhesive capsulitis due to SIRVA were evaluated between June 2021 and December 2022. Demographic and clinical data of the patients were recorded. Pain was evaluated with the Visual Analog Scale (VAS). The passive range of motion (ROM) of the affected shoulder was measured by a goniometer. The applied treatment methods (medical treatment, physical therapy, intraarticular steroid injection, hydrodilatation, and suprascapular nerve block) were recorded. The patients were called in for control two months later. Visual Analog Scale scores and passive shoulder ROMs were reevaluated.

Results

Symptoms started after the second dose in nine (42.9%) patients. The mean time between vaccination and onset of complaints was 8.0±6.4 days. Sinovac vaccine was administered to eight patients, BioNTech vaccine was administered to five patients, and Sinovac+BioNTech vaccine was administered to eight patients. Baseline to control ROM angle changes were 128.8±30.4º to 155.0±20.6° for flexion, 117.1±37.8° to 147.1±26.4° for abduction, 45.9±17.8° to 61.9±12.6° for internal rotation, and 43.4±21.9° to 56.3±18.3° for external rotation, respectively. The mean VAS scores were 7.0±1.2 (5-9) at baseline and 2.7±1.0 (1-5) at the control. There was a statistically significant difference between the baseline and control (two months after treatment) in terms of VAS scores and ROM angles (p<0.001).

Conclusion

Clinicians should be aware of adhesive capsulitis following vaccine administration since a significant improvement can be obtained by proper treatment for SIRVA.

Chronic shoulder injury related to vaccine administration following coronavirus disease 2019 vaccination: a case report

BACKGROUND

Shoulder injury related to vaccine administration, defined as shoulder pain and limited range of motion occurring after administration in the upper arm, has been previously reported. The symptom resolved completely after treatment with oral nonsteroidal anti-inflammatory drugs or an intraarticular steroid injection, however there have been few reports of long-term symptoms following coronavirus disease 2019 vaccination. This case report describes a healthy, middle-aged, healthcare worker who developed post-vaccination subacromial-subdeltoid bursitis that lasted for more than 6 months after Pfizer-BioNTech coronavirus disease 2019 vaccination.

CASE PRESENTATION

A 55-year-old Japanese woman with no significant medical history was vaccinated in the standard site, with the needle direction perpendicular to the skin. Within a few hours after the second vaccination, severe shoulder pain and limited range of motion appeared. Although shoulder range of motion improved, her shoulder pain did not improved for several months, and she consulted an orthopedic doctor 5 months later. Radiographs of her left shoulder did not provide helpful diagnostic information. High intensity in the subacromial-subdeltoid space was seen on short TI inversion recovery of magnetic resonance imaging, showing subacromial-subdeltoid bursitis. She was diagnosed with a shoulder injury related to vaccine administration. The patient was started on an oral anti-inflammatory drug, and the left subacromial space was injected with 2.5 mg of betamethasone with 3 ml of 1% lidocaine without epinephrine every 2 weeks. One month after starting this treatment, since her shoulder pain had not improved, the oral anti-inflammatory drug was switched to tramadol hydrochloride acetaminophen. However, 3 months after switching medication, the shoulder pain continued, and she worked so as to have minimal impact on her shoulder.

CONCLUSION

A case of subacromial-subdeltoid bursitis following a second dose of the Pfizer-BioNTech coronavirus disease 2019 vaccine that lasted many months is reported. Injection technique is a modifiable risk factor, the adverse effects of which could potentially be mitigated with appropriate and relevant training of healthcare providers. To prevent this type of case, the appropriate landmark, needle length, and direction should be confirmed.

Arthroscopic debridement for acute hemorrhagic subacromial bursitis following COVID-19 vaccine administration: A case report

The rapid rollout of vaccinations in response to the COVID-19 pandemic has led to their widespread distribution and administration throughout the world. The benefit of these vaccinations in preventing the spread of the disease and diminishing symptoms in patients who contract COVID-19 has been fervently studied and reported. While vaccinations remain an effective and generally safe method of limiting disease transmission and virus-related mortality, vaccine administration is not completely without risk. Shoulder injuries related to vaccine administration (SIRVA) have been described with previously available vaccines but have yet to be widely reported in the COVID-19 vaccination population. We present a case report of a young, high-functioning patient who presented with acute subacromial bursitis after COVID-19 vaccine administration due to improper vaccination technique. The patient was treated with arthroscopic shoulder surgery and had near immediate relief of shoulder symptoms.

The prevalence and clinical course of shoulder injury related to vaccine administration (SIRVA) after COVID-19 vaccines in Dutch hospital workers

INTRODUCTION

Shoulder Injury Related to Vaccine Administration (SIRVA) is a rare disorder characterized by persistent shoulder pain and limited range of motion presenting within 48 h after vaccine administration. With the widespread distribution of the COVID-19 vaccine, the incidence of SIRVA is expected to rise. This sudden rise in vaccine administration presents an ideal opportunity to estimate the prevalence of SIRVA and to better characterize SIRVA.

OBJECTIVE

This study aims to investigate the prevalence of SIRVA following COVID-19 vaccine administration among hospital workers in the Netherlands.

METHODS

A questionnaire was sent to all hospital workers from a single non-academic hospital in the Netherlands. Respondents who had active SIRVA complaints were invited for an outpatient orthopaedic clinic assessment. Data was collected on participant characteristics and physical examination including assessment of active and passive range of motion (ROM). An ultrasound was performed to identify potential abnormalities.

RESULTS

32 out of 981 (3.3%) respondents reported shoulder pain with limited ROM occurring within 48 h after vaccine administration lasting for at least 7 days. Of these 32 respondents with SIRVA, 18 (56.2%) still reported active symptoms at the time of the survey. Clinical examination of 13 (72.2%) respondents with active SIRVA complaints showed limited glenohumeral ROM, limitations in activities of daily living and injection site pain. Twelve out of thirteen (92.3%) respondents with active SIRVA complaints showed abnormalities of the soft-tissue of the shoulder on ultrasound. Physiotherapy was the most common treatment modality for persistent SIRVA complaints (38.9%).

CONCLUSIONS

The prevalence of SIRVA is estimated at 3% in the adult working population. Signs and symptoms of SIRVA are variable in severity, localization and timing. Soft-tissue abnormalities is the most common clinical sign. This study contributes to clinician's knowledge on SIRVA, aiding in early recognition and treatment, which are imperative for prevention of persistent and severe shoulder pathology.

Chronic stage magnetic resonance imaging findings in patients with shoulder injury related to vaccine administration (SIRVA)

PURPOSE

Identify chronic shoulder MRI findings in patients with known shoulder injury related to vaccine administration (SIRVA).

MATERIALS AND METHODS

Two fellowship-trained musculoskeletal radiologists retrospectively reviewed the MRI of nine patients with clinically established SIRVA. MRI was performed at least 4 weeks after vaccination and included intravenous contrast-enhanced sequences. MRI was reviewed for the presence of erosions, tendonitis, capsulitis, synovitis, bone marrow oedema, joint effusion, bursitis, cartilage defects, rotator cuff lesions, and lymphadenopathy. The number and location of focal lesions were recorded.

RESULTS

Erosions of the greater tuberosity were present in 8/9 (89%), tendonitis of the infraspinatus muscle tendon in 7/9 (78%), capsulitis, synovitis, and bone marrow oedema in 5/9 (56%) cases, respectively. Effusion was found in three, and subdeltoid bursitis, rotator cuff lesions as well as cartilage defects in one patient, respectively. None of our included subjects showed axillary lymphadenopathy.

CONCLUSION

In this case series, greater humeral tuberosity erosions, infraspinatus muscle tendonitis, capsulitis, synovitis, and bone marrow oedema were common MRI findings in chronic SIRVA.

SIRVA: Shoulder injury related to vaccine administration

Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is "too high" and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability.

Refractory shoulder injury related to vaccine administration: correlation with culture presence of Cutibacterium acnes

Background

Shoulder pain following intramuscular administration of vaccine is common. However, a small number of patients experience prolonged pain and dysfunction atypical to normal transient postvaccination shoulder pain. Shoulder Injury Related to Vaccine Administration (SIRVA) remains incompletely understood, whether a robust immune response to vaccine antigen or inappropriate injection technique with needle placement in synovial or bursal tissue, or some combination of the two. Symptoms overlap with those of Cutibacterium acnes (C. acnes) infection but the relationship between the two, if any, has not been evaluated.

Methods

Clinical case files were reviewed for 3 cases of SIRVA with positive cultures for C. acnes were reviewed. Presentation, treatment, and clinical outcomes were compared.

Results

In all cases, patients were thin (body mass index < 23), females, who had high injection placement of a vaccine, all patients had positive magnetic resonance imaging findings of increased signal in the subacromial bursa, and/or greater tuberosity. All patients underwent arthroscopic débridement and culture harvest and cultures were positive for C. acnes. A combination of oral and intravenous antibiotics was used, and all patients demonstrated clinical improvement from the preoperative state.

Discussion

This case series presents 3 patients with refractory SIRVA who ultimately underwent arthroscopic irrigation and débridement with culture biopsy. Each case had culture results positive for C. acnes and all responded, at least partially, to arthroscopic débridement and intravenous antibiotic therapy. The purpose of this manuscript is to raise awareness of potential coexistence of SIRVA and C. acnes which may be of assistance to surgeons treating refractory cases of SIRVA.

Does COVID-19 vaccine exacerbate rotator cuff symptoms? A prospective study

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) is a rare but increasing complication after vaccination. The aim of this study was to increase awareness of post-vaccination shoulder pain and to investigate the effect of the clinical condition of the shoulder before vaccination on the loss of function that may occur after vaccination.

METHODS

This prospective study included 65 patients aged > 18 years who were diagnosed with unilateral shoulder impingement and/or bursitis. The first vaccination was performed on the shoulders with rotator cuff symptoms, then the second vaccination was performed on healthy shoulders of same patients as soon as the health system allowed. Pre-vaccination MRI of the symptomatic shoulders of the patients was performed and VAS, ASES and Constant scores were evaluated. At 2 weeks after vaccination of the symptomatic shoulder, scores were reassessed. For the patients with changes in the scores, MRI was performed again and the treatment of all patients was started. A second vaccination was given to asymptomatic shoulders and the patients were recalled two weeks later and their scores were evaluated.

RESULTS

After vaccination, the symptomatic shoulder of 14 patients was affected. No clinical changes were observed in the asymptomatic shoulders after vaccination. The VAS scores of the symptomatic shoulders evaluated after vaccination were significantly higher than the scores evaluated before vaccination (p = 0.001). The ASES and Constant scores of symptomatic shoulders evaluated after vaccination were significantly decreased compared to the scores evaluated before vaccination (p = 0.001).

CONCLUSIONS

Exacerbation of symptoms may occur if symptomatic shoulders are vaccinated. Before vaccination, a detailed anamnesis should be taken from the patients and vaccination should be performed to the asymptomatic side.

Adhesive Capsulitis Secondary to COVID-19 Vaccination - A Case Series

Introduction

Shoulder injury related to vaccine administration (SIRVA) is a group of pathologies defined by pain and stiffness after intramuscular administration of vaccine to the upper arm and has been reported after COVID-19 vaccination. We aim to discuss its pathophysiology, clinical presentation, treatment and outcomes.

Materials and methods

We retrospectively identified patients presenting with adhesive capsulitis within four weeks of administration of COVID-19 vaccine to the affected arm at our tertiary institution from March 2021 to December 2022.

Result

Based on the above criteria, we identified seven cases of adhesive capsulitis, comprising one male and six female patients, with average age of 60 years. We present initial symptoms, signs and the duration from when the vaccine was administered. We have highlighted our treatment strategies as well as the clinical and functional outcomes reported by these patients after treatment. We have reported improvement in both Visual Analogue Scale (VAS) and range of motion (ROM) in all our patients after non-surgical management which included physiotherapy and, in some cases, hydrodilatation.

Conclusion

SIRVA related adhesive capsulitis is rare and under-reported with limited information in current literature. This study highlights that adhesive capsulitis is a potential complication arising from improper COVID-19 vaccine administration and reinforces traditional wisdom of administering vaccinations on the non-dominant arm. Conservative treatment strategies appear to be effective, particularly hydrodilatation combined with physiotherapy, and patients are expected to have a good return of function.

Optimizing needle length and site choice for adult immunization

BACKGROUND

Current recommendations for needle length and vaccination site for intramuscular deltoid vaccinations are backed by minimal data.

AIM

To determine the ideal needle length and vaccination site for intramuscular deltoid vaccine administration.

METHODS

120 shoulder CT scans were evaluated and grouped by patient weight and sex as recommended by the United States CDC: Group 1, <60 kg, Group 2, 60-70 kg, Group 3, females 70-90 kg and males 70-118 kg, and Group 4, females > 90 kg and males > 118 kg. For each group, distance from skin to deltoid fascia and deltoid muscle width were measured at 2, 4, and 6 cm distal to the posterolateral corner of the acromion for 5 unique trajectories. Needle lengths of 0.625″, 1.0″, and 1.5″ were simulated at each site to determine inoculation location relative to the deltoid.

RESULTS

For Group 1, a 0.625″ needle in the mid-lateral (ML) trajectory 4 cm distal to the posterolateral corner provided a perfect rate of successful inoculations (100 %). For Groups 2-3, a 1″ needle in the posterolateral (PL) trajectory 4 cm distal provided high rates (>80 %) of successful intramuscular inoculations with low rates of overpenetration (<15 %) while minimizing risk to the axillary nerve. For Group 4, a 1.5″ needle using the same strategy provided the highest rate of successful inoculations (96 %) and minimal overpenetration (4 %). Overpenetration was associated with more anterior and superior injection sites (P < 0.001 for both) for all needle lengths.

CONCLUSIONS

The overall ideal injection site to maximize successful intramuscular vaccine administration, minimize overpenetration, and avoid axillary nerve injury is 4 cm distal to and in line with the posterolateral corner of the acromion, a site more posterior and inferior than current CDC recommendations. We caution against use of a 1.5″ needle for patients < 118 kg due to high predicted rates of overpenetration.

Atypical progress of frozen shoulder after COVID-19 vaccination: A case report

BACKGROUND

After vaccination was mandated worldwide, various adverse effects associated with the coronavirus disease 2019 (COVID-19) vaccination, including shoulder pain, have been reported. Here, we report a case of new-onset shoulder pain after BNT162b2 (Comirnaty, Pfizer-BioNTech) mRNA vaccination.

CASE SUMMARY

A 50-year-old man visited our rehabilitation center with left shoulder range of motion (ROM) limitation that had persisted for more than 5 mo. The history included no specific noteworthy events, except vaccination. The pain in the patient's left deltoid muscle appeared 1 day after the second BNT162b2 vaccination and intensified to severe pain. The patient self-administered aspirin, with which the pain subsided immediately, whereas ROM limitation persisted. At the first visit, the patient complained of dull pain and ROM restriction of the left shoulder (flexion 130°, abduction 110°, and external rotation 40°). Among the diagnostic studies conducted for the evaluation of the shoulder, magnetic resonance imaging showed a thickened coracohumeral ligament. Nerve conduction studies and needle electromyography showed no electrodiagnostic abnormalities. The patient received comprehensive rehabilitation for 7 mo and had an overall improvement in pain and ROM of the left shoulder.

CONCLUSION

In this case of severe shoulder pain after COVID-19 vaccination that subsided immediately with aspirin treatment, the exact cause and mechanism of pain are unclear. However, the clinical symptoms and diagnostic workups in our report suggest the possibility that the COVID-19 vaccination triggered an immunochemical response that resulted in shoulder pathology.

Shoulder Injury Related to Vaccine Administration: Case Series

Objective  Shoulder pain is a common presentation in the primary care setting, and shoulder pain after vaccination has a growing body of literature. The present study sought to understand how a standardized treatment protocol would aid patients experiencing shoulder injury related to vaccine administration (SIRVA). Methods  Patients experiencing SIRVA were retrospectively recruited between February 2017 and February 2021. All patients were treated with physical therapy and offered a cortisone injection. Post-treatment range of motion (i.e., forward elevation, external rotation, internal rotation) and patients' reported outcomes were collected with the visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), simple shoulder test (SST), and single assessment numeric evaluation (SANE) scores. Results  A total of 9 patients were retrospectively examined. Among them, 6 patients presented within one month of a recent vaccination event, while 3 patients presented 67, 87, and 120 days after vaccination. Furthermore, 8 of the patients completed physical therapy, and 6 of them underwent a cortisone injection. The follow-up time averaged 8 months. At final follow-up, the mean external rotation was 61° (standard deviation, SD ± 3°) and the mean forward elevation was 179° (SD ± 45°). Internal rotation ranged between L3 and T10. The VAS pain scores were 3.5/10.0 (SD ± 2.4), the mean ASES score was 63.5/100.0 (SD ± 26.3), and the SST scores were 8.5/12.0 (SD ± 3.9). Finally, the SANE scores were 75.7/100.0 (SD ± 24.7) and 95.7/100.0 (SD ± 6.1) in the injured and contralateral shoulders respectively. Conclusion  Shoulder pain after a vaccination treated with physical therapy and cortisone injection ultimately resulted in favorable shoulder range of motion and functional score outcomes. Level of Evidence  IV.

Emergency Department Treatment Provides Immediate and Durable Relief Following Vaccine Injury: A Case Report

INTRODUCTION

Intramuscular administration of vaccines into the deltoid muscle is the recommended route for most vaccines in adults. Ectopic injection into the subdeltoid/subacromial bursa can produce an inflammatory bursitis that is associated with significant long-term morbidity.

CASE REPORT

We describe a novel approach to treatment of this condition: ultrasound-guided administration of dexamethasone by the emergency physician within six hours of vaccine administration. This approach resulted in complete and durable long-term resolution of symptoms with no functional impairment.

CONCLUSION

This outcome is superior to that described for usual care, and the approach is well-suited to emergency physicians.

Calcific tendinitis of the shoulder induced by an mRNA vaccine for COVID-19: A case report

Coronavirus disease 2019 (COVID-19) vaccines have been widely used and have been shown to be effective in combating the pandemic. However, various side effects have been reported following vaccination. For instance, a condition called 'shoulder injury related to vaccine administration' (SIRVA) is characterized by shoulder pain and limited range of motion after intramuscular injection of a vaccine into the deltoid muscle of the shoulder. Despite an increase in SIRVA cases, the exact incidence of the disease is unclear, and there are a few reports of SIRVA about the COVID-19 vaccine. Here, we report a rare case of an 83-year-old woman who was diagnosed with calcification in her left shoulder 1 year ago and developed calcific tendinitis after receiving an mRNA vaccine for COVID-19 (Pfizer-BioNTech). Radiographs showed calcification of the supraspinatus tendon, and magnetic resonance images showed continuous inflammatory findings from the subdeltoid bursa to the subacromial bursa. We treated the patient with celecoxib and acetaminophen, and she recovered after about 2 months. In order to prevent SIRVA, the presence of shoulder joint disease should be carefully asked during a pre-vaccination assessment. The puncture point should be chosen with the median point of the deltoid muscle or the anterior-posterior axillary line as landmarks because the more cephalad the puncture position, the greater the chance of causing SIRVA.

Shoulder injury following COVID-19 vaccine administration: a case series and proposed diagnostic algorithm

BACKGROUND

Shoulder Injury Related to Vaccine Administration (SIRVA) is a preventable adverse event following incorrect vaccine administration, which can result in significant long-term morbidity. There has been a notable surge in reported cases of SIRVA as a rapid national population-based COVID-19 immunization program has been rolled out across Australia.

METHODS

Surveillance of Adverse Events Following Vaccination in the Community (SAEFVIC) in Victoria identified 221 suspected cases of SIRVA following the commencement of the COVID-19 vaccination program, reported between February 2021 and February 2022. This review describes the clinical features and outcomes of SIRVA in this population. Additionally, a suggested diagnostic algorithm is proposed, in order to facilitate early recognition and management of SIRVA.

RESULTS

151 cases were confirmed as SIRVA, with 49.0% having received vaccines at state vaccination centers. 75.5% were suspected incorrect administration site, with most patients experiencing shoulder pain and restricted movement within 24 hours of vaccination, lasting on average 3 months.

CONCLUSION

Improved awareness and education regarding SIRVA is imperative in a pandemic vaccine roll-out. The development of a structured framework for evaluating and managing suspected SIRVA will aid in timely diagnosis and treatment, essential to mitigate potential long-term complications.

Assessment of multiple domains of pain following BNT162b2 mRNA COVID-19 vaccination

Pain at the injection site is the most frequent reaction among COVID-19 vaccine recipients, but its characteristics were not fully described yet. The purpose of this study was to investigate multiple domains of pain following BNT162b2 mRNA vaccination. We included 107 subjects undergoing primary shot of the vaccination twice into deltoid muscle with a 3-week interval. They completed 6 sessions of pain assessments, one before the first and second dose (1-0, 2-0), and 1st/7th day after the first and second dose (1-1/1-7, 2-1/2-7). Pain visual analog scale (VAS), pain distribution, and pressure pain threshold (PPT) on deltoid muscle were evaluated in each session. The mean VAS (at rest/shoulder motion) was 6.0/27.6 mm at 1-1, and 12.8/34.0 mm at 2-1. Approximately, 90% of recipients showed localized pain within the upper arm. Percentage change of PPTs at 1-1 and 2-1 was bilaterally (ipsilateral/contralateral) decreased to 87.4/89.4% and 80.6/91.0%, which was recovered to the baseline level at 1-7 and 2-7. Temporary, mild-to-moderate intensity, localized distribution, concomitant with bilateral mechanical hyperalgesia on the deltoid muscle, were typical pain characteristics following this vaccination. These findings provide a rationale that will be informative for future recipients. J. Med. Invest. 70 : 355-360, August, 2023.

Shoulder Pain and Dysfunction After Vaccination: A Systematic Review

BACKGROUND

Persistent shoulder pain and dysfunction after vaccination are relatively rare but well-known complications after inoculations into the deltoid muscle. The term SIRVA (shoulder injury related to vaccine administration) is frequently used to encompass many of these occurrences; however, multiple distinct pathologies with similar presentations have been reported after vaccination. We performed a systematic review of the literature on vaccine-related shoulder injuries to help guide practitioners in appropriate workup and treatment based on specific diagnoses.

METHODS

PubMed was used to search for combinations of multiple keywords (including vaccine, immunization, SIRVA, injury, inflammation, bursitis, Parsonage-Turner syndrome, and neuritis), and all references of each potential article were reviewed. A total of 56 articles were included. Patient demographics, vaccine information, presentation, diagnostic studies, treatment, and outcomes were recorded.

RESULTS

Diagnoses were divided into 3 categories: (1) local inflammatory reaction (SIRVA), (2) brachial neuritis, and (3) direct nerve injury. The included articles reported on 57 cases of SIRVA, 18 of brachial neuritis, and 4 of direct nerve injury. The diagnoses reported for the SIRVA cases included frozen shoulder, pseudoseptic arthritis, subacromial bursitis, rotator cuff injury, and lytic lesions of the humeral head. Various treatments were used, and most patients had resolution of symptoms with conservative treatment including physical therapy, analgesics, and/or corticosteroid injections. Advanced imaging rarely provided information that affected treatment. The brachial neuritis and direct nerve injury cases were typically confirmed with electromyography/nerve conduction studies. Treatment of these 2 categories was nonoperative in all cases, typically with analgesics and/or corticosteroids, and most patients had symptomatic improvement after a few months, with most patients regaining strength. However, some (1 of 3 patients with brachial neuritis and >1 year of follow-up and 2 of 4 patients with direct injury) had residual weakness.

CONCLUSIONS

Medical professionals should be aware of the various pathologies that can lead to prolonged shoulder pain after vaccination. Fortunately, most of these conditions can be treated successfully with nonoperative modalities, although differentiating among the diagnoses can help guide treatment, as some likely benefit from systemic corticosteroids or localized corticosteroid injections. Outcomes for most patients have been good, with the majority recovering without residual pain or deficits.

LEVEL OF EVIDENCE

Prognostic Level IV.

Aiming too high: Shoulder injury related to vaccine administration (SIRVA): A case series

PURPOSE

Shoulder injury directly related to vaccination (SIRVA) occurs when a vaccine is administered too high in the shoulder. The primary aim of this study was to accurately detail the occurrence, symptoms, diagnosis, management and long-term outcomes of SIRVA cases in Victoria, Australia.

PRINCIPAL RESULTS

The study identified 102 SIRVA cases from 2007 to 2020 from the Surveillance of Adverse Events Following Vaccination in the Community (SAEFVIC) database. The majority [73/85; (86 %)] of cases resolved completely with a median time to resolution of 8 weeks and no statistically significant difference in recovery by immunisation provider type or baseline imaging.

MAJOR CONCLUSIONS

This large case series includes long-term clinical progress in SIRVA, allowing accurate evaluation and analysis. Further evaluation is required to establish if other risk factors contribute to SIRVA, which may help with targeted, tailored education for providers on correct vaccine administration technique, including in large and rapid vaccine rollouts.

Shoulder injury related to vaccine administration following SARS-CoV-2 inoculation: Case series and review of literature

Introduction

Shoulder Injuries Related to Vaccine Administration (SIRVA), describes those cases of shoulder severe post-inoculation complications, including pain and prolonged disability. Most of the reported cases have been secondary to influenza vaccination. This study retrospectively describes a series of 18 patients following SARS-CoV-2 inoculation and compares the findings with those previously reported for other vaccines.

Materials and methods

Inclusion criteria was onset of symptoms within 48 h after injection, symptoms duration of at least seven days, and restricted range of motion in absence of symptoms prior to vaccination. Average age was 59.4 years old (38-76), and 72.2% were women.

Results

In many cases (58%) the initial diagnosis was not clear, which lead to incorrect treatment. The most common pathological finding was subacromial-subdeltoid bursitis (66.6%). All patients who received depot corticosteroids followed by a gentle rehabilitation program showed strong clinical improvement but did not completely resolve the symptoms at 7.2 months average final follow-up. Surgical intervention was necessary in one of the patients due to the persistence of symptoms despite conservative treatment.

Conclusions

Shoulder injury related to vaccine administration is rare, but when present, its torpid evolution makes it difficult to treat. We have found in our case series a similar pattern to that already described for other vaccines. A high index of suspicion helps to pick up the condition promptly and early treatment can bring satisfactory outcome.

Kuduz aşısı uygulamasına bağlı omuz yaralanması: bir olgu sunumu

Reactions at the vaccine injection site are usually mild and transient. Musculoskeletal symptoms, such as myalgia and arthralgia, are commonly seen following vaccination. Shoulder injury related to vaccine administration (SIRVA), defined as shoulder pain and limited range of motion in the shoulder after intramuscular vaccine administration into the upper arm, may occur due to incorrect vaccine administration. Using the appropriate injection technique in the intramuscular administration of vaccines will reduce the risk of SIRVA. In this paper, we report the clinical and magnetic resonance imaging findings of a 26-year-old female patient presenting with SIRVA after rabies vaccination and discuss this case in light of the current literature.

Shoulder injury related to vaccine administration (SIRVA) after COVID-19 vaccination

OBJECTIVE

The global fight against COVID-19 has required mass vaccination clinics as well as mass recruitment of personnel, including many who may not regularly administer intramuscular deltoid immunizations, potentially increasing the incidence of improper intramuscular injection. Shoulder injury related to vaccine administration (SIRVA) is a well-described, preventable injury resulting from improper injection into anatomic structures adjacent to the deltoid muscle leading to mechanical and chemical trauma augmented by an inflammatory immune response to the vaccine and/or adjuvants. SIRVA is best described in the setting of influenza vaccination, and little is known about it as it pertains to COVID-19 vaccination. This study aims to describe SIRVA in the current pandemic, increase clinician awareness, and offer considerations for prevention.

METHODS

To identify clinical characteristics of patients with post-COVID-19-vaccination shoulder injuries, we performed a systematic review of the cases of vaccination-related shoulder injuries reported in the literature and conducted a review of the public Vaccine Adverse Event Reporting System (VAERS).

RESULTS

We identified 305 cases of SIRVA in the VAERS database and 28 cases of SIRVA in the setting of COVID-19 vaccination from the literature (n = 333). Patients had a mean age of 51.8 years and a median of 51.5 (range: 19-90) years. Of these, 76.3% were female and 23.7% male. Most patients sought medical evaluation with 54 of the 305 VAERS cases reporting utilizing emergency services. Of patients with imaging-confirmed SIRVA (n = 95), the most common diagnoses were adhesive capsulitis and bursitis, and the most common symptoms were pain (97.7%) and limited range of motion (68.1%). Most patients reported requiring treatment with the majority receiving physical therapy (56.3%), followed by cortisone injection (34.4%). Other modalities used were non-steroidal anti-inflammatory drugs, oral steroids, and surgery. Only 5 patients from this group reported recovery while 60 stated they had not yet recovered. Of those, 23.3% reported disability.

CONCLUSION

SIRVA should be regarded as an under-reported, significant cause of post-vaccination morbidity. In the setting of COVID-19 mass vaccination, clinicians must be aware of signs and symptoms of SIRVA as well as appropriate diagnostic modalities and treatment options. Additionally, standardization and proper education regarding injection technique and appropriate needle length is imperative to reducing harm.

Isolated Infraspinatus Myositis after Intramuscular Vaccine Administration

Case

A 74-year-old female developed left shoulder pain after receiving an influenza vaccine. Her initial physical exam was suggestive of subacromial bursitis, and a corticosteroid injection into the subacromial space resulted in a 50% improvement in her pain. Subsequent MRI demonstrated myositis isolated to the infraspinatus muscle. She was successfully treated with anti-inflammatory medication and physical therapy.

Conclusion

Shoulder injury related to vaccine administration (SIRVA) is a rare clinical complication, and myositis in the rotator cuff musculature has not been previously reported. Proper administration of intramuscular vaccinations should be emphasized to prevent injury to structures surrounding the shoulder joint.

What Do We Know About Shoulder Injury Related to Vaccine Administration? An Updated Systematic Review

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) is postulated to be an immune-mediated inflammatory response to a vaccine antigen injected into or near the subacromial bursae or synovium, leading to shoulder pain and dysfunction. The number of studies on this topic is rapidly increasing. Recent comparative studies have reported conflicting conclusions, which suggests that a systematic review of the best-available evidence may be helpful.

QUESTIONS/PURPOSES

In this systematic review, we asked: What are the (1) clinical characteristics, (2) diagnoses, and (3) management approaches and outcomes reported in association with SIRVA?

METHODS

A search was performed on October 4, 2021, of the PubMed and Medline databases for studies related to SIRVA. Inclusion criteria were English-language comparative studies, case series, and case reports that involved shoulder pain occurring after vaccination. Studies of exclusively neurologic conditions after vaccination were excluded. Forty-two studies met the eligibility criteria, including three retrospective comparative studies (72 patients and 105 controls), five database case series (2273 patients), and 34 case reports (49 patients). Study quality was assessed for the database case series and retrospective comparative studies using the Methodological Index for Non-randomized Studies tool.

RESULTS

Among patients in the case reports, the median age was 51 years (range 15-90 years), and 73% (36 of 49) were women. BMI was reported for 24% of patients (12 of 49) in case reports, with a median of 23.5 kg/m2 (range 21-37.2 kg/m2). The most common symptoms were shoulder pain and reduced ROM. The most common diagnoses were shoulder bursitis, adhesive capsulitis, and rotator cuff tears. The most frequent management modalities included physical or occupational therapy, NSAIDs, and steroid injections, followed by surgery, which was generally used for patients whose symptoms persisted despite nonsurgical management. Full resolution of symptoms was reported in 2.9% to 56% of patients.

CONCLUSION

The association between inflammatory conditions of the shoulder (such as bursitis) and vaccination appears to be exceedingly rare, occurring after approximately 1:130,000 vaccination events according to the best-available comparative study. Currently, there is no confirmatory experimental evidence supporting the theory of an immune-mediated inflammatory response to vaccine antigens. Although the clinical evidence is limited, similar to any bursitis, typical treatments appear effective, and surgery should rarely be performed. Additional research is needed to determine the best injection technique or evaluate alternate injection sites such as the anterolateral thigh that do not involve positioning a needle close to the shoulder.

Persistent Shoulder Pain After Vaccine Administration Is Associated with Common Incidental Pathology: A Systematic Review

BACKGROUND

Claims of shoulder injury now account for half of all claims to the Vaccine Injury Compensation Program. Reports from databases of claims or potential adverse events note a relatively high mean age and high prevalences of rotator cuff tendinopathy and adhesive capsulitis-common shoulder problems that might be incidental to vaccination. Published case reports provide much more detail about individual patients than is available in databases. A review of published cases provides an opportunity for more detailed review of symptoms, diagnoses, pathology, treatment, and prognosis. Such a review can better assess the relative likelihood that pathologies associated with new persistent shoulder symptoms after vaccination are coincidental or unique to and caused by vaccine.

QUESTIONS/PURPOSES

Regarding published case reports addressing persistent shoulder pain after vaccination: (1) In what proportion of patients was a specific diagnosis made? (2) What diagnoses were most common? (3) Among patients treated nonsurgically, what proportion resolved, and over what time span did they resolve?

METHODS

In August 2020, we searched PubMed and Embase between 2006 and 2020 using the following search strategy: Search 1: (shoulder dysfunction OR shoulder pain OR shoulder bursitis OR rotator cuff tendonitis OR adhesive capsulitis OR glenohumeral arthritis AND [vaccine OR vaccination OR immunization]); Search 2: (shoulder injury related to vaccine administration or SIRVA). The search was supplemented by reviewing reference lists of identified studies. Inclusion criteria were any detailed report of three or fewer cases involving shoulder pain after vaccine administration. Twenty published reports of 29 patients were identified and assessed by two reviewers independently. One reported glenohumeral joint infection was excluded because the relationship between this type of relatively uncommon, discrete diagnosis and vaccination raises different considerations. We assumed a high risk of bias, although we are not aware of bias assessment tool for case reports. We recorded and summarized patient demographics, symptoms, examination and imaging findings, surgery findings, diagnoses, treatments, and outcomes. Seventy-five percent (21 of 28) of patients were women, with a mean age of 54 ± 19 years. In search of an underlying pathology, at least one diagnostic study was performed in 82% (23 of 28) of patients including radiographs in seven, ultrasound in seven, and MRI in 16 patients (some patients underwent more than one type of imaging). We distinguished specific pathophysiological diagnosis from shoulder pain and stiffness, counted the most common diagnoses among patients a specific diagnosis, and tracked symptom resolution among patients treated nonoperatively.

RESULTS

A specific diagnosis was made in 57% (16 of 28) of patients. Twelve patients had pain and limitation of motion due to pain but no specific pathological diagnosis. The most common specific diagnoses were rotator cuff tendinopathy (9 of 16) and adhesive capsulitis (4 of 16). Less common specific diagnoses included rotator cuff arthropathy (and rheumatoid arthritis) and suspected septic arthritis with nonspecific synovitis on arthroscopy. One patient had transient MRI signal change in the humeral head, which was interpreted as osteonecrosis that resolved in a manner not typical for that diagnosis. Of the 17 patients treated nonsurgically, 15 reported resolution, and two had incomplete symptom resolution with the mean 6-month evaluation period.

CONCLUSION

The observation that persistent shoulder pain after vaccination overlaps with common shoulder pathology-both in large databases as well as in more detailed reports of specific patients as analyzed in this review-establishes a high probability of a coincidental rather than a causal association. In the absence of high-quality experimental evidence of vaccine-specific shoulder pathology, in our opinion, it seems safest and healthiest to assume that perceived shoulder injury related to vaccine administration (SIRVA) is due to misinterpretation of new symptoms from established pathology rather than a new, vaccine-specific pathology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Risk for Shoulder Conditions After Vaccination: A Population-Based Study Using Real-World Data

BACKGROUND

Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited.

OBJECTIVE

To estimate the risk for shoulder conditions after vaccination and assess possible risk factors.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Southern California, a large integrated health care organization.

PARTICIPANTS

Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017.

MEASUREMENTS

A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared.

RESULTS

Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons.

LIMITATION

Generalizability to other health care settings, use of administrative data, and residual confounding.

CONCLUSION

These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

SIRVA (Shoulder Injury Related to Vaccine Administration) following mRNA COVID-19 Vaccination: Case discussion and literature review

Shoulder injury related to vaccine administration (SIRVA) is an increasingly recognised complication after vaccination and presents with significant shoulder pain and stiffness. SIRVA is thought to occur as a result of improper administration of vaccine into the subdeltoid bursa or shoulder joint. This results in an inflammatory cascade that damages the structures in the shoulder region. The incidence of SIRVA is relatively higher for influenza vaccination due its widespread administration. We present a reported case of SIRVA following a mRNA COVID-19 vaccination and review the current literature. As we embark on a worldwide scale of COVID-19 vaccination, it is of utmost important that we use proper vaccination techniques and screen patients at risk of SIRVA. This would improve the efficacy of the vaccine and improve the outcomes of the vaccination programme.

Shoulder Injury Related to COVID-19 Vaccine Administration: A Case Series

Background: A shoulder injury related to vaccine administration (SIRVA) is a vaccination complication that can affect daily life activities. To date, there have been no case series of patients diagnosed as SIRVA following a COVID-19 vaccination. We offer a series of seven SIRVA cases including clinical presentations, investigations and treatment outcomes. Methods: A retrospective chart review was performed for seven patients who developed SIRVA following a COVID-19 vaccination between April 2021 and October 2021. All patients had no prior shoulder pain before their vaccination and then developed shoulder pain within a few days following the vaccination, which did not spontaneously improve within 1 week. Results: Four of the seven patients were male, and the average age was 62.29 ± 7.76 years. The average body mass index was 25.1 ± 2.2 kg/m². In all cases, the cause of the SIRVA was from an incorrect COVID-19 vaccine administration technique. Two patients developed shoulder pain immediately following the injection, one patient about 3 h after the injection, and the other four patients within the next few days. Two of the seven patients visited the orthopedic clinic after the persistent shoulder pain for 3 and 4 days and the other five patients 1–9 weeks following their injections. One of the seven patients was treated with combined intravenous antibiotic and oral non-steroidal anti-inflammatory drug (NSAID) because septic arthritis of the shoulder could not initially be ruled out, and recovered within 2 weeks. The other six patients had shoulder pain without acute fever, and five of them were treated with only oral prednisolone 30 mg/day for 5–10 days, following which the pain improved and they all could return to normal activities within 14 days, with no side effects from the prednisolone such as stomachache, nausea, vomiting, headache, or dizziness. Discussion and conclusion: In our series, the most common cause of SIRVA was an incorrect vaccination technique. Most patients responded well to oral NSAIDs or oral prednisolone. Clinical relevance: All SIRVAs were from an incorrect injection technique and not actually the vaccination, so our series highlights the importance of ensuring all vaccinators understand the importance of taking proper care with the injection technique. Additionally, most of our patients with SIRVA from a COVID-19 injection responded well to oral prednisolone (30 mg/day). If there are no contraindications, we suggest this as the first line treatment for COVID-19-related SIRVA.

Prolonged shoulder dysfunction after coronavirus disease vaccination: A case of shoulder injury related to vaccine administration

Shoulder pain is a common symptom after intramuscular vaccination. However, only a few cases of shoulder joint injury have been reported after coronavirus disease 2019 vaccination. A 52-year-old woman experienced clinically significant pain in the left shoulder joint after receiving the first dose of a coronavirus disease 2019 vaccine. She neglected the shoulder pain, hoping that it would spontaneously improve without medical attention. However, the pain continued with obvious limitations in shoulder movement and function. After 8 months, she presented to the outpatient clinic with a frozen left shoulder. Such rare consequences of vaccinations, known as shoulder injury related to vaccine administration, can be prevented by using an appropriate needle gauge and length according to the patient’s sex and weight with the correct injection site away from shoulder structures.

[Not Available]

Shoulder injury related to vaccine administration(SIRVA) is een zeldzame en ondergerapporteerde complicatie van vaccinatie in de bovenarm. Patiënten met SIRVA hebben (soms heftige) schouderklachten die passen bij een subacromiaal pijnsyndroom of glenohumerale klachten. De klachten houden vaak weken tot maanden aan en beperken de patiënten in hun dagelijkse bezigheden. SIRVA ontstaat wanneer een intramusculaire injectie (deels) wordt toegediend in de onderliggende niet-musculaire weefsels. Dit veroorzaakt een ontstekingsreactie en kan leiden tot bursitis, tendinitis of een glenohumerale capsulitis. Vanwege de grote hoeveelheid vaccinaties in de huidige COVID-19-pandemie is het van belang dat huisartsen oog hebben voor deze complicatie.

Shoulder Injury Related to Vaccine Administration and a Growing Challenge: A Focused Review

ABSTRACT

Shoulder injury related to vaccine administration (SIRVA), an entity that causes acute shoulder pain and may limit range of motion (ROM) after vaccination, is a condition where a small but significant percentage of patients are experiencing in light of the current push for mass immunizations against SARS-CoV-2 worldwide. A search of literature related to SIRVA was performed across multiple electronic databases. Women, patients reporting vaccine injection location to be too high, and patients without prior history of shoulder pain were the most common historical factors in those experiencing SIRVA. Tenderness to palpation and limited shoulder ROM were the most associated physical examination findings. When using magnetic resonance imaging, tendinopathy, subacromial-subdeltoid bursitis, and rotator cuff tears (partial or complete) were the most common findings. Radiographic imaging rarely aided the diagnosis. SIRVA is an entity that health care providers should be aware of to improve the care of patients that may experience these symptoms after vaccine administration.

Frozen Shoulder Related to Influenza Vaccine Administration

Shoulder pain is often a transient physical finding after vaccination. We present the case of a 46-year-old woman who presented clinically with frozen shoulder that was progressively worse and temporally related to her yearly influenza vaccination. The patient failed conservative management, and 7 months postvaccination, the patient underwent shoulder manipulation under anesthesia with good results. Vaccination-related shoulder dysfunction after high-deltoid intramuscular penetration and infiltration into the subdeltoid/subacromial bursa can cause a severe local inflammatory response that clinically may present as frozen shoulder. A case report and review of the literature on suspected frozen shoulder injury related to vaccine administration is presented. A greater understanding of the shoulder anatomy and use of the correct intramuscular vaccination administration technique is important to prevent this rare postvaccination complication.

Frozen shoulder after COVID-19 vaccination

Background

The data on frozen shoulder and shoulder injury related to vaccine administration (SIRVA) after coronavirus disease 2019 (COVID-19) vaccination are absent from the literature. Hence, the purpose of this case series was to describe the clinical presentation and short-term follow-up of patients who developed frozen shoulder after COVID-19 vaccination.

Methods

In the present study, 10 patients (9 women and 1 man) with a mean age of 53 ± 8 years (range, 43-68 years) who presented to the shoulder surgeon’s practice center with painful stiffness of the shoulder after COVID-19 vaccination between June 1 and September 30, 2021, were retrospectively evaluated.

Results

All 10 patients had normal radiographs and were diagnosed as frozen shoulder. Eight patients (80%) had a comorbidity during presentation (4 patients with hypothyroidism, 3 patients with diabetes mellitus, and 1 patient with prediabetes/hyperglycemia). Symptoms developed immediately after the vaccination in 6 patients (60%), at 48 hours in 1 patient (10%), and at 10 days in 3 patients (30%). The mean pain visual analog scale score was 6.5 ± 1.9 (range, 2.5-8), and both active and passive range of motion were limited in all the patients at the time of presentation.

Conclusion

The musculoskeletal specialists who will see such patients with painful shoulder stiffness should be aware of the frozen shoulder diagnosis, which can occur after COVID-19 vaccination, so that such patients can be identified and treated early.

Shoulder Injury Related to Vaccine Administration: Diagnosis and Management

Shoulder injury related to vaccine administration (SIRVA) is a rare but potentially debilitating injury characterized by persistent shoulder pain, typically occurring within 48 hours of intramuscular deltoid vaccine administration. With over 150 million flu vaccines being administered in the United States each year, and the US Centers for Disease Control’s goal of immunizing greater than 70% of the population for the coronavirus disease 2019 virus, cases of SIRVA can be expected to rise. A search of current literature was done to identify published material corresponding to incidence, diagnosis, and treatment of SIRVA. Most events have been associated with poor needle placement and/or a local reaction to the delivered serum during vaccine administration. Shoulder injury related to vaccine administration events can lead to persistent and possibly permanent injury. Clinical evaluation involves a thorough history, physical examination, and often diagnostic studies including radiographs, magnetic resonance imaging, and nerve studies. Treatment is individually directed and should initially consist of observation and local symptom management. Recalcitrant cases or infections may warrant surgical intervention. Published outcomes vary widely, and our understanding of SIRVA remains limited. Large-scale studies are necessary to better understand the pathophysiology of SIRVA, its treatment, and its outcomes. Overall, the initial priority in managing SIRVA should be awareness and prevention.

Health economic analyses of secondary vaccine effects: a systematic review and policy insights

INTRODUCTION

: Numerous analyses demonstrate substantial health economic impacts of primary vaccine effects (preventing or mitigating clinical manifestations of the diseases they target), but vaccines may also be associated with secondary effects, previously known as non-specific, heterologous, or off-target effects.

AREAS COVERED

: We define key concepts to distinguish primary and secondary vaccine effects for health economic analyses, summarized terminology used in different fields, and perform a systematic review of health economic analyses focused on secondary vaccine effects (SVEs).

EXPERT OPINION

: Health economists integrate evidence from multiple fields, which often use incomplete or inconsistent definitions. Like regulators and policy makers, health economists require high-quality evidence of specific effects. Consistent with the limited evidence on mechanisms of action for SVEs, the associated health economic literature remains highly limited, with 4 studies identified by our systematic review. The lack of specific and well-controlled evidence that supports quantification of specific SVEs limits the consideration of these effects in vaccine research, development, regulatory, and recommendation decisions and health economic analyses.

Ultrasonic aspiration for vaccination-related shoulder dysfunction

Background

Chronic shoulder pain occurs rarely after a vaccination and is hypothesized to arise from the effects of unintentional vaccine injection into the subacromial bursa, rotator cuff, capsule or underlying bone. The avascular nature of the rotator cuff, as well as unknown genetic and environmental factors, may predispose to the persistence of pain and disability, referred to as vaccination-related shoulder dysfunction and shoulder injury related to vaccine administration (SIRVA).

Methods

Ultrasonography, sonopalpation and ultrasound-guided anesthetic injections were used to locate the anatomical source of chronic (mean 20, range 8–42 months) shoulder pain after a vaccination in a consecutive series of 5 patients. Subsequently ultrasound-guided ultrasonic aspiration and debridement was performed using a 2.1 mm outer cannula with an inner needle vibrating at 28 kHz. Outcomes were assessed using the Quick Disabilities of the Arm, Shoulder and Hand (QDASH) scale at 2, 4, 12, 24 weeks and 1 year.

Results

The distal infraspinatus and teres minor tendons, their insertions and or the adjacent bone were the source of pain in all 5 patients. The mean QDASH score improved from 65 points to 11 points at 2 weeks (P = 0.001), and to 1 point at 4 weeks after the procedures (P = 0.003). Improvements in pain and function remained stable at 1 year in 3 patients, for at least 24 weeks in 1 patient who died of unrelated causes, and 1 year in 1 patient for posterior shoulder pain who after a pain free interval developed anterior shoulder pain related to his previously asymptomatic osteoarthritis (P = 0.013).

Conclusion

The distal infraspinatus and teres minor tendons, their insertions and adjacent bone are a common source of chronic shoulder pain after a vaccination. Ultrasound-guided ultrasonic aspiration and debridement is a potentially effective treatment for resolving pain and restoring function.