shoulder injury related to vaccine administration (SIRVA)
introduction
Shoulder injury related to vaccine administration, or SIRVA, is an uncommon but emerging phenomenon caused by an improper technique or landmarking for intramuscular deltoid injections. It has likely been more common over the past one to two years secondary to more vaccinations being administered and is likely something that you will encounter in a sports medicine practice.
In 2010, shoulder injury related to vaccine administration (SIRVA) was described by Atanasoff and colleagues as the rapid onset of shoulder pain and dysfunction persisting as a complication of deltoid muscle vaccination in a case series of 13 patients [1]. Influenza vaccine–based studies showed an incidence of 1 to 2 per million and SIRVA is expected to become more prevalent as vaccination numbers grow worldwide[2]. One recent study documenting fifty two cases showed seventy percent women with seventy percent caucasian. The median age was 43 years old with ten different vaccinations identified with no injury pattern associated with any particular vaccine. The mean duration was 143 days and surgical referral was required for 7.6% [3].
In 2017, SIRVA was included in the Vaccine Injury Compensation Program (VICP), a federal program that can provide compensation to individuals injured by certain vaccines [4]. A diagnosis of SIRVA can be considered in patients who experience pain within 48 hours of vaccination, have no prior history of pain or dysfunction of the affected shoulder prior to vaccine administration, and have symptoms limited to the shoulder in which the vaccine was administered where no other abnormality is present to explain these symptoms (eg, brachial neuritis, other neuropathy). Currently, patients with back pain or musculoskeletal complaints that do not include the shoulder following deltoid vaccination do not meet the reporting criteria for SIRVA in the VICP [4].
Cook and colleagues used anthropomorphic data to evaluate the potential for injury to the subdeltoid/subacromial bursa and/or the axillary nerve. Based on these data, they recommended safe IM vaccine administration can be assured by using the midpoint of the deltoid muscle located midway between the acromion and deltoid tuberosity with the arm abducted to 60° [5-6]. In 46% of SIRVA cases described by Atanasoff and colleagues, patients reported that the vaccine was administered “too high.[1]” The study also recommended that the clinician and the patient be in the seated position to ensure proper needle angle and location of administration. For most adults, a 1-inch needle is appropriate for vaccine administration in the deltoid; however, in females weighing < 70 kg and males < 75 kg, a 5/8-inch needle is recommended to avoid injury [4].
Image 1: SIRVA related anatomy. Adopted from [4].
There is no standardized approach for the evaluation of SIRVA. Awareness of SIRVA and a high index of suspicion are necessary to evaluate patients with shoulder concerns post vaccination. The key to recognizing SIRVA is that the pain will often begin within 48 hours of vaccine administration and will not improve with over-the-counter analgesics. Months may pass by and patients may still complain of increasing pain, weakness and impaired mobility/function. Hesse et al. identified the following shoulder complaints: shoulder pain (93.9%), range of motion limitation (31.1%), tingling or paresthesia (7.8%), erythema (5.5%), and shoulder weakness (4.8%). The type of vaccine for this study varied, with the influenza vaccine being the most prevalent [6].
Image 2. Correct needle placement for deltoid injection Adopted from [10].
physical examination
The physical examination will be dependent on many things including timing of vaccination and underlying condition. Adhesive capsulitis may cause decreased range of motion. Subacromial/subdeltoid bursitis may show signs of impingement on special testing including Hawkins and Neers maneuvers. There may be weakness with abduction or weakness with rotator cuff strength testing. Overall, the provider needs to be aware that there may be many different findings on physical examination.
imaging/diagnostics
Laboratory evaluation should be considered to evaluate for other potential diagnoses such as infection, autoimmune or rheumatoid disorders. Plain radiographs are many times performed but may not be helpful with the diagnosis. Ultrasound can confirm the evidence of bursitis and can be used to further evaluate or rule out rotator cuff injuries. MRI findings vary but include intraosseous edema, bursitis, tendonitis, and rotator cuff tears. A wide array of conditions and findings have been reported [1]. Complete rotator cuff tears were found in 15% of cases reviewed by Atanasoff and colleagues with the majority being done within three months of symptom onset [1].
In cases of neurologic complaints consisting of pain, numbness, tingling, paresthesias, and weakness, an electrodiagnostic evaluation may also be warranted. Nerve conduction studies and EMGs should be performed at least 2-3 weeks after vaccination in order for any potential nerve injury to begin its cascade of myelin sheath and axonal sheath changes, for the study to be able to identify it [7].
Image 3: Symptoms depending on location. Adopted from [10].
treatment
Treatment of SIRVA and other vaccine-related shoulder injuries typically involved NSAIDs, corticosteroid injections and physical therapy. The rarity of cases and incomplete understanding of the pathophysiology has led to varying patient-centered treatment plans focused on individualized symptom relief. One study reported corticosteroid injections into the bicipital groove, glenohumeral joint and subacromial/subdeltoid bursa before resolution of symptoms [8]. Local corticosteroid injections were used in about 60 percent of two other studies [1,6].
For advanced noninfectious and non neurologic SIRVA shoulder complaints that are unresponsive to initial nonsurgical management surgical intervention to repair damaged tissue may be warranted. Atanasoff et al and Hesse et al reported that surgery was performed in 30.8% and 32.5% of patients, respectively [1,6]. This decision should be made collaboratively between the patient and physician and should be considered only when all other treatment options have been exhausted.
For neurologic complaints, the initial treatment strategy is also nonsurgical management consisting of rest, activity modification, anti-inflammatory medication, nerve modulating medication, and physical therapy. Medications include NSAIDs, as well as nerve modulating agents such as gabapentin and pregabalin. Therapy should focus on joint mobilization, deltoid and rotator cuff muscle strengthening, and nerve gliding and desensitization. In cases with prolonged documented nerve injury or secondary nerve impingement, surgical intervention such as nerve decompression may be warranted.
outcomes and future direction
The long-term outcome of SIRVA is not well-documented and many times patients are lost to follow up. The data that are available show that the majority of SIRVA patients report residual pain with permanent decreased range of motion after treatment. Hesse et al reported that only 24% of the 476 patients who petitioned claims to the VICP between 2010 and 2016 had full resolution of symptoms [6]. Similarly, Atanasoff et al. reported that only 31% of the 13 patients in their study reported complete recovery [1]. Other smaller case reports and series have varying degrees of resolution.
Beyond better understanding and treating SIRVA, the initial priority should continue to focus on prevention through sound injection technique. Emphasis should be placed on choosing the correct syringe, needle gauge, and needle length. The syringe choice may vary from 1 mL to 3 mL, the needle gauge may vary from 22 gauge to 25 gauge, and the length may vary from 0.625 inches to 1.5 inches, based on age and body habitus [9]. Increased attention should be placed on needle length, as a needle that is either too short or too long may lead to improper administration and possible complications if the needle penetrates too deeply. Needle placement during intramuscular administration is into the thickest portion of the deltoid muscle and the recommended angle is 90 degrees and approximately 2 inches below the acromion process, and just below the level of the armpit.
Summary
In conclusion, shoulder injury related to vaccine administration (SIRVA) is a possibly under reported diagnosis that results from improper technique or landmarking for intramuscular deltoid injections. Symptoms usually persist for greater than 48 hours and can cause significant shoulder pain and decreased shoulder function. Each case should be patient-centered in regards to treatment plans and should focus on individualized symptom relief. Current literature emphasizes the mechanism of SIRVA injury, as well as present-day clinically endorsed preventative strategies. Still, there remains a lack of literature exploring diagnosis and treatment as it relates to clinical outcomes and large-scale studies that emphasize long-term treatment outcomes are necessary.
Image 4. Proposed algorithm for SIRVA. Adopted from [9].
– Read More @ Wiki Sports Medicine: https://wikism.org/Shoulder_Injury_Related_To_Vaccine_Administration
References
- Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA) Vaccine. 2010;28(51):8049–8052.
- Hibbs, 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.
- Housel, Laurie, et al. “Shoulder Injury Related to Vaccine Administration: The DoD Experience.” Journal of Allergy and Clinical Immunology 145.2 (2020): AB70.
- Health Resources and Services Administration, Health and Human Services Administration. National vaccine injury compensation program: revisions to the vaccine injury table. [Accessed June 3, 2019].
- 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.
- Cook IF. Best vaccination practice and medically attended injection site events following deltoid intramuscular injection. Hum Vaccin Immunother. 2015;11(5):1184–1191.
- 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.
- Arias, LH Martín, et al. “Risk of bursitis and other injuries and dysfunctions of the shoulder following vaccinations.” Vaccine 35.37 (2017): 4870-4876.
- Bodor M, Montalvo E. Vaccination-related shoulder dysfunction. Vaccine. 2007;25(4):585–587
- Szari, Maj Sofia, et al. “Shoulder injury related to vaccine administration: a rare reaction.” Federal Practitioner 36.8 (2019): 380.
- Wood, Chelsey T., and Asif M. Ilyas. “Shoulder injury related to vaccine administration: diagnosis and management.” Journal of Hand Surgery Global Online (2022).
