Shoulder Injury Related to Vaccine Administration: Diagnosis and Management

Abstract

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. 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. Mild shoulder discomfort is a common and well-recognized side effect of intramuscular deltoid injection associated with vaccination administration. Most cases are typically self-limited.1Centers for Disease Control and PreventionPossible Side Effects From Vaccines.https://www.cdc.gov/vaccines/vac-gen/side-effects.htmGoogle Scholar However, individuals occasionally experience severe and persistent shoulder pain that requires further workup and management.2US Health Resources & Services AdministrationNational Vaccine Injury Compensation Program.http://www.hrsa.gov/Vaccinecompensation/Google Scholar These injuries, referred to as “shoulder injury related to vaccine administration” (SIRVA), typically occur moments to days after vaccine injection and can result in prolonged and even permanent shoulder dysfunction.3Gabler L. Staubli J. Hayney M.S. Preventing shoulder injury related to vaccine administration.J Am Pharm Assoc (2003). 2019; 59: 599-600Google Scholar Although uncommon, with influenza vaccine–based studies showing an incidence of 1 to 2 per million, SIRVA is expected to become more prevalent as vaccination numbers grow worldwide.4Hibbs B.F. Ng C.S. Museru O. et al.Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.Vaccine. 2020; 38: 1137-1143Google Scholar Effective treatment for SIRVA begins with prevention, followed by accurate diagnosis and timely treatment. Nearly 50% of the United States population receives the flu shot annually, representing over 150 million vaccinations per year.5Centers for Disease Control and PreventionFlu Vaccination Coverage, United States, 2019–20 Influenza Season.https://www.cdc.gov/flu/fluvaxview/coverage-1920estimates.htmGoogle Scholar Now, with the coronavirus disease 2019 (COVID-19) pandemic, the US Centers for Disease Control and Prevention is aiming for a vaccination goal of 70% of the population.6Centers for Disease Control and PreventionCOVID-19.https://www.cdc.gov/coronavirus/2019-ncov/index.htmlGoogle Scholar Moreover, depending on which vaccination is given, the initial COVID-19 vaccination requires up to 2 injections.6Centers for Disease Control and PreventionCOVID-19.https://www.cdc.gov/coronavirus/2019-ncov/index.htmlGoogle Scholar Additionally, a booster injection, which will likely become annual, is now being recommended for adults.7Centers for Disease Control and PreventionCOVID-19 Vaccine Booster Shots.https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html?s_cid=11706:mrna%20covid%20booster:sem.ga:p:RG:GM:gen:PTN:FY22Google Scholar These 2 vaccinations, for influenza and COVID-19, will represent the most common annual vaccinations. It is currently unclear whether the Centers for Disease Control and Prevention will recommend children under the age of 16 years receive the COVID-19 booster.7Centers for Disease Control and PreventionCOVID-19 Vaccine Booster Shots.https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html?s_cid=11706:mrna%20covid%20booster:sem.ga:p:RG:GM:gen:PTN:FY22Google Scholar However, as it stands, it is estimated that Americans will receive nearly 500 million vaccinations annually.5Centers for Disease Control and PreventionFlu Vaccination Coverage, United States, 2019–20 Influenza Season.https://www.cdc.gov/flu/fluvaxview/coverage-1920estimates.htmGoogle Scholar,8Centers for Disease Control and PreventionCOVID Data Tracker.https://covid.cdc.gov/covid-data-tracker/#vaccinationsGoogle Scholar As such, it can be anticipated that cases of SIRVA will be expected to climb. The incidence of SIRVA is not well-known, but is assumed to be uncommon. Shoulder injury related to vaccine administration was not officially added to the National Vaccine Injury Compensation Program (VICP) Vaccine Injury Table until 2017. However, shoulder injury claims had been substantially increasing for over a decade.4Hibbs B.F. Ng C.S. Museru O. et al.Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.Vaccine. 2020; 38: 1137-1143Google Scholar Petitions to the VICP increased from 2.5% of total claims of SIRVA in 2011 to 41.9% of total claims in 2016.9Hesse E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar Of these, the majority of reported SIRVA cases were female, making up 82.8% of SIRVA petitioner claims to the VICP from 2010 to 2016.9Hesse E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar This majority was reflected in a large cohort study done by Hesse et al,10Hesse E.M. Navarro R.A. Daley M.F. et al.Risk for subdeltoid bursitis after influenza vaccination: a population-based cohort study.Ann Intern Med. 2020; 173: 253-261Google Scholar in which 69% of cases were female. The age associated with SIRVA varied widely, ranging from 19 to 89 years.11Martín Arias L.H. Sanz Fadrique R. Sáinz Gil M. Salgueiro-Vazquez M.E. Risk of bursitis and other injuries and dysfunctions of the shoulder following vaccinations.Vaccine. 2017; 35: 4870-4876Google Scholar,12Gonzalez A.I. Kortlever J.T.P. Moore M.G. Ring D.C. Influenza vaccination is not associated with increased number of visits for shoulder pain.Clin Orthop Relat Res. 2020; 478: 2343-2348Google Scholar The type of vaccine also varied; however, the influenza vaccine predominated.9Hesse E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar Some studies suggest that the growing incidence of SIRVA reports may not be due to increasing injury, but instead to previously underreported events.4Hibbs B.F. Ng C.S. Museru O. et al.Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.Vaccine. 2020; 38: 1137-1143Google Scholar A search of the US Vaccine Adverse Event Reporting System showed that of the approximately 996 million doses of influenza vaccine distributed in the United States from July 2010 to June 2017, there were 1,220 reports of atypical shoulder pain that began within 48 hours of vaccine administration and lasted for greater than 7 days. This made up 2% of all reported Vaccine Adverse Event Reporting System cases.4Hibbs B.F. Ng C.S. Museru O. et al.Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.Vaccine. 2020; 38: 1137-1143Google Scholar Since then, the percent of cases reported has remained relatively consistent at 2%.4Hibbs B.F. Ng C.S. Museru O. et al.Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.Vaccine. 2020; 38: 1137-1143Google Scholar Contrarily, Hesse et al10Hesse E.M. Navarro R.A. Daley M.F. et al.Risk for subdeltoid bursitis after influenza vaccination: a population-based cohort study.Ann Intern Med. 2020; 173: 253-261Google Scholar suggests that the incidence is much lower. A population-based study of nearly 3 million persons receiving an influenza vaccine during the 2016 to 2017 influenza season only identified 16 cases of bursitis.10Hesse E.M. Navarro R.A. Daley M.F. et al.Risk for subdeltoid bursitis after influenza vaccination: a population-based cohort study.Ann Intern Med. 2020; 173: 253-261Google Scholar This study, though, limited its evaluation to subacromial bursitis, a single type of SIRVA injury. The incidence of SIRVA due to COVID-19 vaccination is still unknown, although a number of COVID-19 vaccine SIRVA case studies have recently been published.13Chuaychoosakoon C. Parinyakhup W. Tanutit P. Maliwankul K. Klabklay P. Shoulder injury related to Sinovac COVID-19 vaccine: a case report.Ann Med Surg (Lond). 2021; 68: 102622Google Scholar,14Rodrigues T.C. Hidalgo P.F. Skaf A.Y. Serfaty A. Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA).Skeletal Radiol. 2021; 50: 2293-2297Google Scholar A larger study is still necessary to understand the association of SIRVA and COVID-19 vaccination to determine whether it differs in presentation and incidence from other vaccines, such as influenza. Most instances of SIRVA are associated with errant placement of the needle and/or local reaction to the delivered serum during administration of the vaccine.3Gabler L. Staubli J. Hayney M.S. Preventing shoulder injury related to vaccine administration.J Am Pharm Assoc (2003). 2019; 59: 599-600Google Scholar Most vaccinations, including those for influenza and COVID-19, require intramuscular placement of the vaccine into the deltoid muscle of the The deltoid muscle is the of shoulder The of the and the shoulder and the and subacromial and subdeltoid to the shoulder and and is the nerve the The of the nerve is approximately et of a for the nerve on 2021; Scholar errant injection can potentially of injection into the shoulder can shoulder or or an or injection into the can a injury or of the injection into the subacromial or subdeltoid can and/or shoulder injection into or the nerve can nerve and and even of the from or deltoid injection at can potentially a local and can result in bursitis, or depending on the and of the and the a local reaction to the delivered serum can local and pain, including of the deltoid and bursitis of the subacromial This reaction may be due to injury or an to the vaccine or vaccine The most common of the are such as and in the vaccine, and Vaccine Vaccine Res. Scholar The most common in the influenza vaccine is Vaccine Vaccine Res. Scholar COVID-19 vaccines, from and as a of The COVID-19 vaccine for Disease Control and PreventionCOVID-19 Vaccine Booster Shots.https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html?s_cid=11706:mrna%20covid%20booster:sem.ga:p:RG:GM:gen:PTN:FY22Google at for SIRVA. The is The the most and of the nerve is et of a for the nerve on 2021; and by or in a and Shoulder injury related to vaccine administration.J Am Orthop 2021; Scholar suggest that SIRVA should be as a of the This has the to lead to further injury. is to a in the and of injury, making it for an errant injection to lead to and S. in and Shoulder 2017; Scholar Additionally, as there is an in in injury with it is for an initial injury to be to and to become to and S. R. R. 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Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA).Skeletal Radiol. 2021; 50: 2293-2297Google Scholar also reported on a that shoulder pain following COVID-19 vaccine The a female, shoulder pain within of receiving initially the injury with and with to experience pain and of resonance and an lead to a diagnosis of bursitis and The was on and a physical It is unclear whether the has T.C. Hidalgo P.F. Skaf A.Y. Serfaty A. Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA).Skeletal Radiol. 2021; 50: 2293-2297Google Scholar The US of Health and Services has an annual goal of 70% of the population for influenza and With in vaccine there will likely also be an in SIRVA better understanding and SIRVA, the initial priority should to on injection should be on the needle and needle The may vary from 1 to 3 the needle may vary from to and the may vary from to on age and L. Staubli J. Hayney M.S. Preventing shoulder injury related to vaccine administration.J Am Pharm Assoc (2003). 2019; 59: 599-600Google for Disease Control and needle and Scholar should be on needle as a needle that is or may lead to administration and the needle placement during intramuscular administration is into the of the deltoid It is recommended that the needle should be at a into the of the deltoid approximately 2 the and the of the L. Staubli J. Hayney M.S. Preventing shoulder injury related to vaccine administration.J Am Pharm Assoc (2003). 2019; 59: 599-600Google Scholar This however, the nerve at in have a of et of a for the nerve on 2021; Scholar It may be to as the placement the nerve at and the at a the deltoid muscle is than its more of SIRVA to the VICP have increased each for with an on in vaccine claims of SIRVA to E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar The VICP was in as a to the of and vaccines, vaccination and This to vaccine by vaccine from and the of the of it a to for that have due to Health Resources & Services AdministrationNational Vaccine Injury Compensation Program.http://www.hrsa.gov/Vaccinecompensation/Google Scholar This is however, as et A.I. Kortlever J.T.P. Moore M.G. Ring D.C. Influenza vaccination is not associated with increased number of visits for shoulder pain.Clin Orthop Relat Res. 2020; 478: 2343-2348Google Scholar it is to injury from a of studies have to the incidence of SIRVA it is that cases or and that the incidence is still It be to that for within the Vaccine Adverse Event Reporting Published that the number of SIRVA cases reported to the VICP to each as the number of administered to the E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar of SIRVA in children is still Of the identified reported to the VICP from 2010 to only 1 was years E.M. Atanasoff S. Hibbs B.F. et al.Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.Vaccine. 2020; 38: 1076-1083Google Scholar literature the of SIRVA injury, as as there remains a of literature diagnosis and treatment as it to outcomes. Large-scale studies that treatment outcomes are

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