11 July 2022: Clinical Research
Shoulder Injury Related to Vaccine Administration (SIRVA) in 16 Patients Following COVID-19 Vaccination Who Presented to Chiropractic, Orthopedic, and Physiotherapy Clinics in Hong Kong During 2021Eric Chun-Pu Chu1ABCDEFG*
Med Sci Monit 2022; 28:e937430
BACKGROUND: Shoulder injury related to vaccine administration (SIRVA) occurs when an intramuscular deltoid injection is administered into the shoulder joint. This observational study describes clinical features in 16 patients with SIRVA following Coronavirus 2019 (COVID-19) vaccination who presented to chiropractic, orthopedic, and physiotherapy clinics in Hong Kong between January 1, 2021, and January 1, 2022.
MATERIAL AND METHODS: Adults age ≥18 with new-onset shoulder pain and imaging-confirmed shoulder pathology were retrospectively identified from 35 clinics. Patient demographics and clinical and vaccination details were extracted from the electronic medical record. Shoulder injury was determined by correlating clinical and imaging features.
RESULTS: Of 730 patients with shoulder pain, 16 SIRVA cases (mean age, 49±10 years, 75% female) were identified; (12/16, 75%) of patients received the Pfizer-BioNTech vaccine while (4/16, 25%) received Sinovac-CoronaVac. The most common diagnosis was adhesive capsulitis (10/16, 63%), followed by bursitis (3/16, 19%) and supraspinatus tear (3/16, 19%). Mean symptom onset was 3.5±2.5 days post-vaccination, and always occurred after the 2nd or 3rd vaccination, involving reduced shoulder range of motion (ROM). Mean baseline pain was 8.1±1 (out of 10). All patients received conservative care (eg, exercise, manual therapies). At 3-month follow-up, mean pain reduced to 2.4±1.4; all patients had normal shoulder ROM.
CONCLUSIONS: In the past 2 years, millions of intramuscular COVID-19 vaccinations have been administered. It is important that clinicians are aware of SIRVA as a cause of new symptoms of shoulder injury and should ask the patient about recent vaccinations, including for COVID-19.
Keywords: COVID-19 vaccine, Injection Site Reaction, shoulder pain
Millions of doses of the Coronavirus 2019 (COVID-19) vaccine have been widely administered with efficacy in combating the COVID-19 pandemic . In Hong Kong, the location of the current study, 65% of the population had received at least 1 dose of the COVID-19 vaccine by January 1, 2022 . While local vaccine injection site reactions of pain, redness, and swelling have been well described, these symptoms are generally not serious and are self-limited . Conversely, a potentially more problematic shoulder injury related to vaccine administration (SIRVA) has seldom been described in the literature in relation to COVID-19 vaccination.
SIRVA is defined as shoulder pain and decreased range of motion after receiving a vaccine intended for intramuscular delivery in the upper arm [4,5]. This condition is becoming recognized as a potential vaccine-related adverse effect and has been most often associated with influenza vaccine administration [4,5]. One potential cause of SIRVA is accidental injection into the subdeltoid bursa, causing bursitis, tendinitis, and/or capsulitis .
According to a recent systematic review, SIRVA typically occurs in middle-aged adults (median age 51) and tends to affect females (73% of cases) . The most common diagnoses include bursitis, adhesive capsulitis, and rotator cuff tear [4,5]. SIRVA is typically treated conservatively, which leads to full recovery in 3–56% of patients . Unfortunately, there are limited data regarding the optimal treatment strategy for SIRVA and typical duration of symptoms [4,5].
However, to the best of our knowledge, only 20 cases of SIRVA after COVID-19 vaccination have been reported according to a PubMed search on April 14, 2022 using the terms “shoulder injury related to vaccine administration” and “COVID” [6–14]. Given this limited number of cases, little is known about the clinical features and risk factors for SIRVA after COVID-19 vaccination. Based on the limited data, it appears that SIRVA may occur independent of the type of COVID-19 vaccine used [6–14]. Further, among published cases, adhesive capsulitis and bursitis appear to be more common, with rotator cuff tear being uncommon [6–14].
A thorough shoulder examination is requisite for diagnosis of SIRVA, and includes inspection, palpation, and range of motion testing . Specialized provocative tests are of uncertain utility in suspected cases of SIRVA. Patients with SIRVA often have tenderness at the injection site and a global reduction in shoulder range of motion affecting all planes of motion . MRI may be useful to evaluate for soft-tissue pathology , and can demonstrate findings consistent with inflammation . In the current study, clinical diagnoses of SIRVA based on pain and limited range of motion were compared to and supported by imaging findings.
Despite an increase in overall awareness of SIRVA, few studies have evaluated SIRVA associated with COVID-19 vaccination. Therefore, this observational clinical study describes the presentation and clinical features of SIRVA in 16 patients following COVID-19 vaccination who presented to chiropractic, orthopedic, and physiotherapy clinics in Hong Kong between January 1, 2021, and January 1, 2022.
Material and Methods
The Ethics Committee of the Chiropractic Doctors Association of Hong Kong approved of this study (Causeway Bay, Hong Kong; IRB ID: CDA20221202). Written informed consent for patient information and images to be published was provided by the patient(s) or a legally authorized representative. Data for patients presenting with new shoulder pain were retrospectively collected by querying an electronic medical records system shared between 35 affiliated chiropractic, orthopedic, and physiotherapy clinics in Hong Kong. Data were extracted in March through April 2022 with a search window of January 1, 2021, to January 1, 2022.
Inclusion criteria were patients age ≥18 years with a new concern of shoulder pain, a history of COVID-19 vaccination within 1 month preceding shoulder pain onset, and shoulder pathology confirmed via imaging. Exclusion criteria were a history of influenza vaccination within 1 year of shoulder pain onset, shoulder injury within 1 year preceding shoulder pain onset, shoulder pain in the context of an inconsistent injection site (shoulder pain contralateral to injection site or in a non-shoulder region), radiological features of severe, recent, and/or pre-existing shoulder pathology or non-SIRVA injury including shoulder fracture, tumor, and severe degenerative disease. In addition, patients in which the vaccination history could not be confirmed were excluded. The study flowchart is shown in Figure 1.
Data regarding sex, age, laterality of shoulder affected, vaccine dose, duration between vaccine administration and shoulder pain onset, type of vaccine (Pfizer-BioNTech or Sinovac-CoronaVac), active shoulder range of motion, pain severity (using a visual analog scale of 0–10; 10 being most severe), and type of treatment (medication, steroid injection, manual therapy, exercise therapy, or surgery) were extracted from the electronic medical record. The primary shoulder injury diagnosis (adhesive capsulitis, subacromial-subdeltoid bursitis, or rotator cuff tear) was determined by correlating the clinical and imaging features.
Magnetic resonance imaging (MRI) and shoulder radiographs were interpreted by board-certified medical radiologists. Subacromial and subdeltoid bursitis were defined as distended fluid-filled structures between the deltoid muscle, acromion, and supraspinatus and infraspinatus tendons on MRI . Rotator cuff tears were assessed using fat-suppressed, intermediate-weighted/gradient echo sequences, in which the hyperintense signal region within the tendon frequently corresponded to fluid on T2-weighted imaging .
Diagnosis of adhesive capsulitis was based limited active and passive range of motion and supported by evidence on MRI. Signs of capsulitis on MRI included the subcoracoid triangle sign, joint capsule thickening, coracohumeral ligament thickening >4 millimeters, T2 hyperintensity of the inferior glenohumeral ligament, and soft-tissue thickening within the rotator muscles or biceps anchor .
Descriptive statistics were utilized to calculate percentages for categorical variables and standard deviations for continuous variables.
A total of 730 patients presented with shoulder pain at the 35 included clinics during the study time window, and 26 patients reported that their symptoms began within 1 month following COVID-19 vaccine administration. A total of 26 shoulder MRIs and 6 shoulder radiographic series were analyzed. Sixteen patients met the inclusion criteria while 10 were excluded (Figure 1). No patients had a history of COVID-19 infection preceding their vaccination or developed COVID-19 during the study time window. Included patients were of Asian ethnicity. Three of 16 (19%) of the patients had significant medical comorbidities, including diabetes and/or cardiovascular disease, while no patients had thyroid disease, autoimmune disease, cancer, or Parkinson’s disease.
Of the included patients, 12/16 (75%) were women and 4/16 (25%) were men. At the time of injury, the mean patient age was 49±10 years (Table 1). The mean onset of symptoms was 3.5±2.5 days after vaccination. All patients presented with reduced active shoulder range of motion (Table 2). The baseline mean shoulder pain severity was 8.1±0.8. The injection site and shoulder pain were on the left in 13/16 (81)% of patients and right in 3/16 (19)%. Regarding COVID-19 vaccine type, 12/16 (75%) of patients were administered Pfizer-BioNTech while 4/16 (25%) received Sinovac-CoronaVac.
A primary diagnosis of adhesive capsulitis was most common, occurring in 10/16 (63%) of patients (Figure 2). Subacromial-subdeltoid bursitis and rotator cuff tear (Figure 3) each occurred in 3/16 (19%) of patients. All patients with rotator cuff tear had a supraspinatus tear. No other relevant shoulder pathologies (eg, labrum tear) were identified.
Most patients (13/16, 81%) received manual therapy or exercise therapy for treatment of shoulder pain as provided by a chiropractor or physiotherapist. A minority of patients (3/16, 19%) additionally received medications to treat their shoulder pain, these being nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. All patients completed between 10 and 20 treatments over the course of 3 months, based on a typical treatment plan for shoulder disorders utilized among the affiliated clinics. No patients underwent surgery or steroid injection.
After 3 months of conservative treatment, patients were re-assessed as part of routine clinical care. The average shoulder range of motion improved on flexion (83° to 146°), abduction (80° to 131°), and 90-degree external rotation (30° to 75°), such that each patient went from an abnormal range at baseline to within the normative range (Table 2) . Mean pain severity reduced to 2.4±1.4, with 12/16 (75%) of patients attaining a mild pain severity (≤3 of 10) at 3-month follow-up.
There are several limitations to this study. First, its retrospective nature may increase the chance of bias. For example, there could be recall bias in the sense that patients’ self-report of the onset of shoulder symptoms was inaccurate. Further, cases of SIRVA after COVID-19 administration could have been missed by the medical record query if shoulder injuries were not coded or documented accurately by clinicians. Second, there was selection bias because only patients with shoulder pathology confirmed by imaging were considered; therefore, the study is not representative of a broader population with pain but no radiological findings. Third, there was diagnosis bias as patients were assessed by different clinicians and imaging was interpreted by different radiologists. Fourth, a record of the exact site of vaccine administration in terms of distance from the acromion was not available in most cases, which prevented a definitive conclusion that improper vaccine administration was causative of each case of SIRVA. Fifth, although this series revealed that the rate of SIRVA was low among patients presenting with shoulder pain after COVID-19 vaccination (16 of 730; 2%), the overall prevalence of this condition among vaccinated individuals could not be determined from the current study design. Sixth, in each case, the type of provider administering the vaccine was not clear given this relied on patients’ self-report. However, in most cases this was likely a nurse, and in some cases, this may have been a physician. In Hong Kong, pharmacists do not typically administer vaccines. Finally, because the natural history of SIRVA related to COVID-19 vaccination is not well described, it is possible patients would have recovered without treatment in a similar time frame.
In the past 2 years, millions of intramuscular COVID-19 vaccinations have been administered. It is important that clinicians are aware of SIRVA as a cause of new symptoms of shoulder injury and should ask the patient about recent vaccinations, including for COVID-19.
FiguresFigure 1. Identification of patients with shoulder pain secondary to COVID-19 vaccine administration. Abbreviations: Coronavirus disease 2019 (COVID-19); magnetic resonance imaging (MRI). Figure created by Eric CP Chu using Microsoft Word Version 2205. Figure 2. Imaging features of adhesive capsulitis. Magnetic resonance image (MRI) of the right shoulder; patient 13. On the coronal T2 fat-suppressed sequence (A) the arrow indicates thickening of the inferior joint capsule with hyperintense T2 signal. On the sagittal T2 fat-suppressed sequence (B) the arrow indicates thickening and mild hyperintense signal at the rotator interval. Figure 3. Imaging features of supraspinatus rotator cuff tear. Magnetic resonance image (MRI) of the right shoulder; patient 6. In the coronal T2 fat-suppressed image (A) the arrow points the articular side of a partial tear of the supraspinatus tendon, involving 50% of the tendon thickness. Also noted is underlying marrow edema at the greater tuberosity of the humerus. In the sagittal T2 fat-suppressed image (B), the arrow again points to the articular side of the partial thickness tear of the supraspinatus tendon, further confirming 50% of tendon thickness involvement.
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