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Shoulder Injury Related To Vaccine Administration

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Other Names

  • Shoulder Injury Related To Vaccine Administration
  • SIRVA

Background

  • This page refers to Shoulder Injury Related To Vaccine Administration (SIRVA), a phenomenon in which patients develop shoulder pain due to improper technique or landmarking for intramuscular deltoid injections

History

  • First described by Atanasoff and colleagues in 2010[1]

Epidemiology

  • Influenza Vaccine
    • Incidence of 1 to 2 per million[2]
  • Demographics in one case series[3]
    • Female (70%)
    • Caucasian (70%)
    • Median age is 43

Pathophysiology

Proposed algorithm for SIRVA[4]
  • General
    • Generally characterized as rapid onset of shoulder pain, dysfunction persisting as a complication of deltoid muscle vaccination
    • More common in female Caucasian women in their 40s
  • Diagnosis is clinical and should be considered in patient who meet the following criteria:
    • Pain within 48 hours of vaccination
    • Have no prior history of pain or dysfunction of the affected shoulder prior to vaccine administration
    • Have symptoms limited to the shoulder in which the vaccine was administered where no other abnormality is present to explain these symptoms
    • Note: patients with back pain or other musculoskeletal complaints do not meet the reporting criteria[5]
  • Vaccine's implicated
    • The influenza vaccine is the most commonly implicated
  • Vaccine Injury Compensation Program (VICP)
    • Added in 2017
    • VICP is a federal program that compensates individuals for vaccine-related injuries
  • Proper vaccination technique/ prevention[5]
    • Safe IM vaccine administration can be assured
    • Location
      • Midpoint of the deltoid muscle located midway between the acromion and deltoid tuberosity with the arm abducted to 60°
      • Needle at 90° to arm, approximately 2 inches below the acromion process
    • Patient should be in seated position
    • Needle
      • For most adults, 1 inch needle is appropriate; consider 5/8 inch in adults under 75 kg
      • Gauge 22 to 25
    • Syringe 1 mL to 3 mL
  • Potentially improper technique
    • Atanasoff found 46% of SIRVA cases described the vaccine as administered "too high"[1]
    • Needle that is too short or too long may lead to improper administration

Associated Conditions


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • History
    • Patient should have a history of recent vaccine administration in the affected shoulder
    • There should be no history of previous shoulder disorder prior to the vaccination
    • Pain typically begins within 48 hours of vaccine administration
    • Does not improve with over-the-counter analgesics
    • Over subsequent months, pain, weakness and impaired function may worsen
    • Hesse et all found the following complaints[6]
      • Shoulder pain (93.9%)
      • Range of motion limitation (31.1%)
      • Tingling or paresthesia (7.8%)
      • Erythema (5.5%)
      • Shoulder weakness (4.8%)
  • Physical Exam: Physical Exam Shoulder
    • There are no clear, pathognomonic physical exam findings in SIRVA
    • They may have findings suggesting a variety of conditions
  • Special Tests

Evaluation

  • Diagnosis is clinical and should be considered in patient who meet the following criteria:
    • Have no prior history of pain or dysfunction of the affected shoulder prior to vaccine administration
    • Have symptoms limited to the shoulder in which the vaccine was administered where no other abnormality is present to explain these symptoms
    • Note: patients with back pain or other musculoskeletal complaints do not meet the reporting criteria[5]

Radiographs

MRI

  • May show
    • Intraosseous edema
    • Bursitis
    • Tendonitis
    • Rotator cuff tears

EMG/NCS

  • May be indicated in the event patient develops neuropathic symptoms
    • Including pain, numbness, tingling, paresthesia, weakness

Classification

  • Not applicable

Management

Nonoperative

  • Indications
    • First line approach in all cases
  • General
    • No clear, evidence based guidelines
    • Management generally individualized, focused on symptom relief
  • NSAIDS
  • Corticosteroid Injection
    • Subacromial bursa is likely most common
    • One study reported subacromial, glenohumeral joint and bicipital groove before resolution of symptoms[7]
  • Physical Therapy
  • For patients with nerve related complaints, consider Neuroleptic Analgesics

Operative

  • Indication
    • Failure of conservative treatment
    • No clear guidelines
  • Technique
    • "repair damaged tissue"

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Unknown, no clear guidelines

Complications and Prognosis

Prognosis

  • General
    • Mean duration of symptoms is 143 days[3]
  • Surgical intervention
    • Surgical referral required for 7.6% of cases[3]
    • Two studies have estimated surgical intervention at about 30%[1][6]

Complications

  • Persistent shoulder pain, symptoms
    • Incomplete recovery seems to be common, but data limited to case series only
    • Hesse reported only 24% of patients had full resolution of symptoms[6]
    • Atanasoff reported only 31% of patients had complete recovery[1]

See Also


References

  1. 1.0 1.1 1.2 1.3 1.4 Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA) Vaccine. 2010;28(51):8049–8052.
  2. ibbs, Beth F., et al. “Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017.” Vaccine 38.5 (2020): 1137-1143.
  3. 3.0 3.1 3.2 Housel, Laurie, et al. “Shoulder Injury Related to Vaccine Administration: The DoD Experience.” Journal of Allergy and Clinical Immunology 145.2 (2020): AB70.
  4. Szari, Maj Sofia, et al. “Shoulder injury related to vaccine administration: a rare reaction.” Federal Practitioner 36.8 (2019): 380.
  5. 5.0 5.1 5.2 ​​​​Cook IF. An evidence based protocol for the prevention of upper arm injury related to vaccine administration (UAIRVA) Hum Vaccin. 2011;7(8):845–848.
  6. 6.0 6.1 6.2 Hesse, Elisabeth M., et al. “Shoulder injury related to vaccine administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016.” Vaccine 38.5 (2020): 1076-1083.
  7. Bodor M, Montalvo E. Vaccination-related shoulder dysfunction. Vaccine. 2007;25(4):585–587
Created by:
John Kiel on 30 May 2022 13:45:33
Authors:
Last edited:
30 May 2022 21:41:38
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