A computer rendering of an inflamed shoulder joint next to a syringe drawing from a vial.

Within hours of her first COVID-19 vaccination, Leah Jackson had severe pain in her left shoulder.

The New York City-based veterinarian said the nurse put the shot “exceptionally high” in her left shoulder and hit the bursa rather than the deltoid. When the nurse got resistance, she rerouted the vaccination to the joint space, Jackson said.

As a veterinarian, Jackson is very familiar with injections: “That was just a bad delivery technique,” she told MedPage Today.

She was in severe pain for weeks that did not respond to over-the-counter anti-inflammatory drugs. Her family doctor referred her to a physical medicine and rehabilitation specialist who, after imaging confirmed bursae and joint inflammation, prescribed steroid and lidocaine injections along with physical therapy.

The pain largely disappeared but returned after 6 weeks, albeit to a lesser extent, and a follow-up MRI confirmed persistent bursitis.

Jackson can still do her job as a veterinarian, but lifting animals during surgery, for example, can be painful. Sometimes it hurts when driving a car.

“I just can’t move my arm with certain movements,” she said.

Vaccination-related shoulder injuries (SIRVA) were documented long before COVID-19 vaccination and are most commonly reported after influenza vaccination. However, the medical community cautions that this is a forensic determination rather than an unambiguous diagnosis.

The condition is also plagued by the lack of a solid evidence base and causality is difficult to determine.

Still, most doctors surveyed by MedPage Today say that it is likely that improper injection technique could lead to shoulder injuries and that these problems should be taken seriously and treated appropriately.

“We certainly don’t see a SIRVA pandemic” with COVID vaccines, DJ Kennedy, MD of Vanderbilt University Medical Center in Nashville, told MedPage Today. “It’s really rare, and the literature so far is mostly case reports. But I think it’s perfectly possible” that a vaccine-related shoulder injury will occur.

What is SIRVA?

Keeling told MedPage Today that one reason SIRVA remains in the forensic field is because it is more of a constellation of symptoms and findings than a specific diagnosis.

Symptoms can vary depending on where the deviant shot landed, resulting in various manifestations such as bursitis, tendonitis, or adhesive capsulitis (also known as “frozen shoulder”).

It is generally described as “a combination of shoulder pain and limited range of motion that occurs within 48 hours of vaccination and does not resolve within a week”. It is also different from typical post-injection pain as the pain is more severe and can affect mobility and function.

Treatments generally include anti-inflammatory drugs, corticosteroid injections, and physical therapy. Surgery is sometimes required to treat an underlying pathology, such as an aggravated rotator cuff injury.

Patients with SIRVA often end up at their GP’s first. You can be referred to a specialist such as a physical therapist or an orthopedic surgeon.

“It is the patients with persistent symptoms who are referred to the orthopedic surgeon,” said Keeling. “When physiotherapy and injection don’t work, basic care is on us.”

Physical medicine & rehabilitation medics or physiotherapists also play a big role in treating SIRVA.

“We treat based on a full assessment including medical history and physical findings and imaging if necessary,” said Kennedy. “Then we develop a comprehensive rehabilitation plan … which usually includes daily movement and strengthening exercises.”

Scott Noren, DDS, an oral surgeon in Ithaca, New York, said he also developed significant pain in his left shoulder after his second COVID shot in early February: “It went pretty deep and pretty high,” he told MedPage Today.

An MRI showed fluid was building up in his joint, as well as adhesive capsulitis, he said. Physiotherapy helped improve his range of motion to some extent, but his pain persists. As a maxillofacial surgeon, it is difficult to take x-rays and perform lengthy procedures: “I now have quite a lot of pain even when I am functioning normally,” he said.

Both Noren and Jackson said their insurance covers their medical bills, and they’re both relieved that they can still work, but they’re frustrated that there isn’t federal coverage for SIRVA related to COVID-19 vaccines.

“There is no compensation for something that is painful, debilitating and was a medical error,” said Jackson.

History of SIRVA

Brent Wiesel, Dr of Vaccination. “

They found that the term “SIRVA” was introduced in 2010 by a team of doctors from the Vaccine Injury Compensation Program (VICP) who reported 13 petitioners presenting with severe vaccine-related shoulder pain that lasted for more than 6 months.

In 2012, a report from the National Academy of Medicine concluded that bursitis of the deltoid muscle may be causally linked to immunization. Five years later, SIRVA was included in the Vaccine Injury Table, which regulates permissible claims before federal vaccination courts.

Since then, SIRVA claims have increased from 10 in 2011 to 433 in 2016, according to the paper. As the total percentage of claims, SIRVA increased from 1.8% to 40.7% during this time, they reported.

The Trump administration recently attempted to cut $ 4 billion in SIRVA from the VICP – originally approved by the National Childhood Vaccine Injury Act of 1986 in response to a spate of lawsuits against vaccine manufacturers – on the grounds that that this was due to the improper administration of vaccines and not the vaccine itself. But the Biden government killed the rule in April. Nonetheless, it couldn’t have applied to COVID vaccines, which are covered by a different reimbursement program.

The Wiesel and Keeling article notes that demographics have changed since the VICP was introduced in the late 1980s for vaccination injuries in children, with more than 50% of claims now affecting adults.

While healthcare providers anticipate a sharp increase in reported cases in the coming year given the large volume of COVID vaccinations, Wiesel and Keeling warned that data on the disease are still limited – they are “practically nonexistent in the orthopedic literature” – and that the “current understanding of the diagnostic work-up of SIRVA is limited to the forensic field”.

Shoulder injury and vaccination dish

Instead of falling under the VICP, COVID-19 vaccines fall under the Countermeasures Injury Compensation Program (CICP). Both programs are administered by the Health Resources and Services Administration (HRSA).

A spokesperson for HRSA confirmed to MedPage Today via email that Pfizer’s (Comirnaty) COVID-19 vaccine, despite being fully FDA-approved, is still falling under the CICP and has not yet switched to the VICP.

The HRSA spokesman said the CICP covers “legitimate serious injuries” – generally those that require hospitalization or result in significant disability.

Applicants must provide evidence that the vaccine caused the injury, unless it falls under an Injury Table for CICP. However, such a table does not yet exist for the CICP, said the spokesman.

“A COVID-19 Medical Countermeasure Violation Table is created when there is sufficient data to meet the ‘compelling, reliable, valid, medical and scientific evidence’ standard indicating that the countermeasure covered is directly causing a particular injury” said the spokesman.

With this table in place, those who have not found a “table” violation will have one year to apply for benefits, even if their previous application was denied.

“Until a breach table for COVID-19 countermeasures is established, claims can be made as non-table violations and the right to compensation is determined by the program on a case-by-case basis,” the spokesman said.

Jackson and Noren said SIRVA’s attorneys said their injuries would likely not be compensated under the CICP.

Keeling and Kennedy both emphasized that while SIRVA needs further study, it appears to be rare and that the benefits of vaccinating against COVID-19 far outweigh the potential risks.

“Despite the SIRVA risk, given the remarkable benefits of vaccinations for personal and public health, especially in light of the coronavirus pandemic, we strongly recommend that patients get vaccinations,” states the Wiesel and Keeling paper.

  • Kristina Fiore heads MedPage’s Enterprise & Investigative Reporting team. She has been a medical journalist for more than a decade, and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Send story tips to [email protected] follow