Progressive osteolysis and surface chondrolysis of the proximal humerus following influenza vaccination

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.

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.

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.

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.

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.

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.

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.

Progressive Monoarticular Inflammatory Arthritis Following Influenza Vaccination

Musculoskeletal injury is an uncommon but usually self-limited complication of vaccine administration. We present a case of progressive inflammatory monoarthritis of the shoulder characterized by bone erosion, bursitis, and severe synovitis caused by an influenza vaccine administered to the ipsilateral deltoid region. Clinical symptoms began within 2 hours of vaccination, with progressive decline in function over 6 weeks. Magnetic resonance imaging examinations performed 5 months apart demonstrated progressive erosive changes of the greater tuberosity, rotator cuff injury, and extensive enhancing synovitis of the glenohumeral joint and subacromial/subdeltoid bursa. After the exclusion of septic arthritis and osteomyelitis, the patient underwent nonoperative treatment and experienced near-complete recovery at 32 months. Although inflammatory arthritis of the shoulder following vaccination is rare, there have been previous reports of it. Clinicians and radiologists need to be aware of this potential complication to ensure an accurate diagnosis.

Shoulder Injury after Vaccination: A Systematic Review

Adverse reactions to vaccine injections are usually mild and incredibly rare in nature, but multiple cases of shoulder events including bursitis, generalized pain or decreased range of motion have been reported following routine vaccine administrations. These events are known as Shoulder Injury Related to Vaccine Administration or SIRVA. A systematic review of literature was performed to identify all published accounts of SIRVA. Twenty-seven papers reporting one or more accounts of SIRVA were identified. The most common vaccination involved was the Influenza vaccine. The most common symptoms were pain that began in 48 hours or less and loss of shoulder range of motion. The most common treatment modalities were physical therapy, corticosteroid injections and anti-inflammatory medication; but in some patients, surgery was required. Regardless of intervention, the vast majority of outcomes demonstrated improved pain and functional except in the occasions of nerve injury. The etiology of SIRVA injuries has multiple possibilities including needle length, mechanical injury from needle overpenetration and the possibility of an immune inflammatory response from the vaccine components, but a unique definitive test or quantifiably result does not yet exist.

Influenza Vaccination Is Not Associated with Increased Number of Visits for Shoulder Pain

BACKGROUND

Shoulder injury from vaccination was approved for automatic compensation from the Vaccine Injury Compensation Program (VICP)-a federal government program started in 1988 to shield the manufacturers of childhood vaccines from liability. The approval was made on the basis of case reports rather than experimental evidence. This, combined with the addition of influenza vaccination to the VICP in 2005 (which broadened coverage to include adults) and other social factors, was associated with a rapid rise in the number of claims of shoulder injury from vaccination over the last decade, which now account for more than half of all claims to the VICP. Given the high prevalence of newly symptomatic sources of shoulder pain such as rotator cuff tendinopathy, combined with the high prevalence of annual influenza vaccinations, there is a substantial risk of overlap leading to the post hoc ergo propter hoc fallacy ("after this, therefore because of this") contributing to misdiagnosis and inappropriate management of patients that perceive injury from vaccination. Records of medical care after a large number of vaccinations have a good chance of detecting serious shoulder pathology, even it is uncommon, which would result in an increased prevalence of visits for shoulder problems and specific types of shoulder pathology.

QUESTIONS/PURPOSES

Is there a difference in the proportion of visits for shoulder pain within 3 months before and after vaccination among students and faculty receiving an influenza vaccination in the shoulder?

METHODS

We studied people who were vaccinated for influenza between 2009 and 2018 at a university health service. During the study period, a comprehensive billing database identified 24,206 influenza vaccinations administered to 12,870 people (median age 20 years, range 16-77; 57% women). We had 80% power to detect a 0.1% increase in the proportion of shoulder problems after vaccination compared with before vaccination. Visits with coded ICD-9 shoulder diagnoses were identified from the electronic medical record. We compared the proportion of shoulder evaluations within 3 months before and 3 months after vaccination.

RESULTS

With the numbers available, the proportion of visits for shoulder problems were not different before (1.1% [52 of 4801]) and after vaccination (1% [40 of 3977], risk ratio 1.1 [95% CI 0.8 to 1.5]; p = 0.72). Among all vaccinations, 49% (11,834 of 24,206) were preceded or followed by an appointment within 3 months before (20% [4801 of 24,206]), after (16% [3977]), or both before and after (13% [3056]) vaccine administration, and 1.4% (170) of these visits were related to a shoulder issue. The most common reason for shoulder-related appointments was atraumatic shoulder pain (79% [134 of 170]).

CONCLUSIONS

Shoulder symptoms sufficient to seek care are notably common, even among relatively young adults, and are not more common after vaccination. Although this does not rule out an important rare pathology specific to vaccination, it seems important to consider the potential harms of assuming, based largely on chronology, that persistent shoulder pain after vaccination-something expected to be common based merely on the anticipated frequency of overlap of vaccination and common shoulder problems-represents harm from vaccine.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Postvaccinal complications and management of suspected cases]

In all developed countries there is the possibility to protect oneself from vaccine-preventable diseases. However, not all individuals make use of this option. It is precisely in highly developed countries where a trend to vaccination hesitancy is noticeable, i. e. reluctance to get oneself or one's children vaccinated. The reasons why this is so are many, but the most important reason is the fear of postvaccinal complications, especially of those that imply sequelae or those with fatal outcomes.Whereas there are some proven associations between vaccination and adverse drug reaction, for example febrile seizures after the measles-mumps-rubella (MMR) vaccination, other hypotheses can be refuted, for example autism after the MMR vaccination. On one hand, this article gives an overview of known postvaccinal complications with indication of a causal association with vaccination and on the other hand addresses hypotheses of potential adverse drug reactions that have been refuted by pharmacoepidemiological studies.Only the scientific debate of these hypotheses, which are repeatedly discussed, especially on social media, can contribute to corroborating or refuting a potential causal association. If evidence for a causal association grows, e. g. intussusception, the relevant authorities (e.g. Paul Ehrlich Institute, European Medicines Agency) will take risk-minimizing measures. If studies and meta-analyses do not reveal any evidence of a causal association, a targeted information strategy will be required in order to prevent myths from circulating, vaccination coverages from declining, and infectious diseases from spreading.

The safety of influenza vaccines in children: An Institute for Vaccine Safety white paper

Most influenza vaccines are generally safe, but influenza vaccines can cause rare serious adverse events. Some adverse events, such as fever and febrile seizures, are more common in children than adults. There can be differences in the safety of vaccines in different populations due to underlying differences in genetic predisposition to the adverse event. Live attenuated vaccines have not been studied adequately in children under 2 years of age to determine the risks of adverse events; more studies are needed to address this and several other priority safety issues with all influenza vaccines in children. All vaccines intended for use in children require safety testing in the target age group, especially in young children. Safety of one influenza vaccine in children should not be extrapolated to assumed safety of all influenza vaccines in children. The low rates of adverse events from influenza vaccines should not be a deterrent to the use of influenza vaccines because of the overwhelming evidence of the burden of disease due to influenza in children.

Onset of Frozen Shoulder Following Pneumococcal and Influenza Vaccinations

OBJECTIVE

Adhesive capsulitis has been suggested as an adverse effect of vaccine administration into the shoulder area. The purpose of this case series is to report 3 cases of acute onset of adhesive capsulitis following pneumococcal and influenza vaccines.

CLINICAL FEATURES

Patients reported painful shoulder and limited motion following routine vaccination. After clinical examination, a diagnosis of adhesive capsulitis was noted.

INTERVENTION AND OUTCOME

All 3 patients were treated conservatively with physical therapy (active ranges of motion and active-assisted motion), nonsteroidal anti-inflammatory drugs, and activity modification with eventual resolution of symptoms.

CONCLUSION

Reports implicating vaccination with adhesive capsulitis are rare. This case series raises the awareness of pneumococcal and influenza vaccinations as possible causes of adhesive capsulitis that appear to respond to standard treatment. Although vaccines are of tremendous importance in the prevention of serious illness, we emphasize the importance of administering them at the appropriate depth and location for each patient.

Bone erosion and subacromial bursitis caused by diphtheria-tetanus-poliomyelitis vaccine

Revaxis(®) is a vaccine against diphtheria, tetanus and poliomyelitis (dT-IPV). This vaccine should not be administered by the intradermal or intravenous route. Poor injection techniques and related consequences are rare. We report a case of bursitis associated with reactive glenohumeral effusion complicated by bone erosion occurring after injection of the dT-IPV vaccine. A 26 year old patient was admitted for painful left shoulder causing functional impairment. Control magnetic resonance imaging showed bone oedema on the upper outer part of the humeral head, with a slight cortical irregularity, indicating that the vaccine was injected in contact with the bone at this location, causing erosion. Outcome was favourable after intra-articular corticosteroids. Reports of articular or periarticular injury after vaccination are extremely rare, in view of the substantial number of vaccines administered every year. The potential complications of vaccination are well known to general practitioners but under-reported in the literature.

Best vaccination practice and medically attended injection site events following deltoid intramuscular injection

Analysis of medically attended injection site events data provides a vehicle to appreciate the inadequacies of vaccination practice for deltoid intramuscular injection and to develop best practice procedures. These data can be divided into 3 groups; nerve palsies, musculoskeletal injuries and cutaneous reactions and reflect inappropriate site of injection, needle over or under penetration, local sepsis and vascular complications. The aim of this review is to formulate best vaccination practice procedures for deltoid intramuscular injection of vaccines through the collation and analysis of medically attended injection site events.

Magnetic resonance imaging of abnormal shoulder pain following influenza vaccination

The influenza vaccine is increasingly available to the general public and mandated by many employers in the United States. The prevalence of post-vaccination complications is likely on the rise. Complications are well known to general clinicians, but are under-reported in the imaging literature. We present four cases of post-vaccination shoulder pain with magnetic resonance imaging (MRI) findings. An intrasubstance fluid-like signal in deep muscular and/or tendinous structures was the most common finding on MRI of these four cases. Focal bone marrow signal within the humeral head and inflammatory changes in the subacromial/subdeltoid bursa were also observed. The most likely reason for a humeral intraosseous edema-like signal was presumed injection of vaccine substance directly into osseous structures that might lead to focal osteitis. In the published literature, there is little emphasis on the imaging of local injection site complications accompanying influenza vaccination. We intended to increase familiarity of MRI findings in the setting of prolonged or severe clinical symptoms following influenza vaccination through the imaging findings of these four cases.