Shoulder Injury Related to Vaccine Administration: Diagnosis and Management
2022; Elsevier BV; Volume: 4; Issue: 2 Linguagem: Inglês
10.1016/j.jhsg.2021.12.009
ISSN2589-5141
AutoresChelsey T. Wood, Asif M. Ilyas,
Tópico(s)Shoulder Injury and Treatment
ResumoShoulder 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 shoulder. The deltoid muscle is the main driver of shoulder joint motion. The joint itself consists of the glenohumeral "ball and socket" joint, the surrounding shoulder capsule, and the overlying rotator cuff and surrounding subacromial and subdeltoid bursa (Figure 1, Figure 2). Traveling inferior to the shoulder joint and then wrapping around posteriorly and laterally is the axillary nerve supplying the deltoid. The distance of the acromion-to-axillary nerve distance is approximately 6.1 ± 0.89 cm (men, 6.57 ± 0.83 cm; women, 5.72 ± 0.75 cm).15Schwarz A.M. Weiglein A.H. Schwarz U.M. et al.Definition of a risk zone for the axillary nerve based on superficial landmarks.Plast Reconstr Surg. 2021; 147: 1361-1367Google Scholar An errant injection can potentially injure any of these structures (Table 1). An injection placed too deep into the shoulder capsule can cause shoulder joint or bursal inflammation (synovitis) or an infection (septic arthritis or bursitis). An injection placed into the rotator cuff can cause a rotator cuff injury (tendonitis or tear of the rotator cuff). An injection placed into the subacromial or subdeltoid space can cause painful inflammation (bursitis) and/or frozen shoulder (adhesive capsulitis). An injection placed into or near the axillary nerve can cause nerve irritation, numbness and tingling (paresthesia), and even weakness of the arm from temporary anterior or middle deltoid paralysis. An injection at any location can potentially cause a local infection, and can result in cellulitis, abscess, septic bursitis, septic arthritis, or osteomyelitis, depending on the depth and location of the infection and the host immune status. Lastly, a local inflammatory reaction to the delivered serum can cause local irritation and pain, including myositis of the deltoid and bursitis of the subacromial space. This adverse reaction may be due to tissue injury or an allergic response to the vaccine or various vaccine components. The most common sources of the adverse allergic reactions are proteins, such as egg products and gelatin. Other sources include yeast, commonly found in the human papillomavirus vaccine, and latex.16Chung E.H. Vaccine allergies.Clin Exp Vaccine Res. 2014; 3: 50-57Google Scholar The most common reactive source found in the influenza vaccine is egg protein.16Chung E.H. Vaccine allergies.Clin Exp Vaccine Res. 2014; 3: 50-57Google Scholar Both COVID-19 messenger RNA vaccines, from Pfizer-BioNTech and Moderna, contain polyethylene glycol as a possible source of allergy. The J&J/Janssen COVID-19 vaccine contains polysorbate, another potential source.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 ScholarFigure 2Anatomic structures at risk for SIRVA. The overall mean acromion-to-nerve distance is 6.1 ± 0.89 cm. The interval between the most proximal and distal borders of the axillary nerve is 1.39 ± 0.35 cm.15Schwarz A.M. Weiglein A.H. Schwarz U.M. et al.Definition of a risk zone for the axillary nerve based on superficial landmarks.Plast Reconstr Surg. 2021; 147: 1361-1367Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 1Anatomic Location and Potential Injuries Caused by SIRVAAnatomic LocationPotential InjuriesDeltoid muscleMyositisAbscessSubacromial spaceBursitisSeptic bursitisRotator cuffTendonitisTear or ruptureGlenohumeral jointAdhesive capsulitisSeptic arthritisAxillary nerveNeuritisNeuropathy Open table in a new tab Wiesel and Keeling17Wiesel B.B. Keeling L.E. Shoulder injury related to vaccine administration.J Am Acad Orthop Surg. 2021; 29: 732-739Google Scholar suggest that SIRVA should be treated as a chronic, idiopathic inflammatory response of the shoulder. This response has the potential to lead to further tissue injury. Inflammation is known to play a role in the development and progression of tendon injury, making it possible for an errant injection causing tendonitis to lead to tissue breakdown and rotator cuff injury.18Abraham A.C. Shah S.A. Thomopoulos S. Targeting inflammation in rotator cuff tendon degeneration and repair.Tech Shoulder Elb Surg. 2017; 18: 84-90Google Scholar Additionally, as there is an in increase in asymptomatic chronic rotator cuff injury with progressing age, it is possible for an initial injury to already be present prior to immunization and to become symptomatic secondary to synovial inflammation and irritation.19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google Scholar Greater than 50% of the population over the age of 65 has a rotator cuff tear; hence, the chances of an acute-on-chronic event increases with age.18Abraham A.C. Shah S.A. Thomopoulos S. Targeting inflammation in rotator cuff tendon degeneration and repair.Tech Shoulder Elb Surg. 2017; 18: 84-90Google Scholar Most vaccine injection–related shoulder complaints are self-limited and resolve within 24 to 48 hours.20Veera S. Chin J. Kleyn L. Spinelli S. Tafler L. Use of osteopathic manipulation for treatment of chronic shoulder injury related to vaccine administration.Cureus. 2020; 12e9156Google Scholar A small subset of patients go on to experience prolonged and debilitating shoulder pain, often diagnosed as SIRVA. This term was first coined by Atanasoff et al19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google Scholar in a 2010 case series describing 13 petitioners to the VICP who all experienced shoulder pain and decreased range of motion for greater than 6 months after vaccine injection. Additional diagnostic criteria for SIRVA varies between resources. These often include a lack of prior symptomatic shoulder pain, rapid onset of pain that usually occurs either immediately or less than 4 days following vaccination, and symptoms localized to the vaccinated shoulder.19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google Scholar The typical presenting complaints could include shoulder pain, decreased range of motion, or general shoulder weakness, as well as paresthesia or tingling (Table 2). Hesse et al9Hesse 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 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. Most cases (68.7%) reported that the pain began the day of vaccination, while 13.1% of cases experienced pain starting the second day. The time to resolution was not specified.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 Similarly, in a case series of 13 patients published by Atanasoff et al,19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google Scholar shoulder pain was reported in 100% of patients, limited range of motion was reported in 85%, altered sensation was reported in 31%, and weakness was reported in 31%. The type of vaccine varied, with the influenza vaccine being the most prevalent. The onset of pain was immediate for 54% of patients, occurred within 24 hours for 39% of patients, and occurred within 4 days for 8% of patients. Symptoms persisted between 6 months and many years.19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google ScholarTable 2Reported Symptoms or Diagnosis, Treatment, and Resolution of SIRVAAuthorPatients, nReported Symptoms or Diagnosis%Treatmentsn (%)Resolution, n (%)Atanasoff et al19Atanasoff S. Ryan T. Lightfoot R. Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA).Vaccine. 2010; 28: 8049-8052Google Scholar13Shoulder painLimited ROMAltered sensationWeakness10084.630.830.8NSAIDsSteroid injectionPhysical therapySurgery8 (61.5)8 (61.5)6 (46.2)4 (30.8)4 (30.8)Chuaychoosakoon et al13Chuaychoosakoon 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 Scholar1Shoulder painLimited ROMFever100Intravenous antibiotics1(100)1(100)Cross et al29Cross G.B. Moghaddas J. Buttery J. Ayoub S. Korman T.M. Don't aim too high: avoiding shoulder injury related to vaccine administration.Aust Fam Physician. 2016; 45: 303-306Google Scholar2Shoulder painLimited ROMSupraspinatus tear10010050Surgical joint washoutSteroid injection1 (50)1 (50)2 (100)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 Scholar16Subdeltoid bursitis100SurgerySteroid injection4 (25)1 (6.3)2 (12.5)Hesse et al9Hesse 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 Scholar476Shoulder painRotator cuff problemsBursitisLocal reactionAdhesive capsulitisAdverse effects of vaccinationNeuritisImpingementOtherNot specified31.913.911.88.25.52.52.31.99.718.5Physical or occupational therapySteroid injectionsNSAIDs or other analgesicsSurgeryOral steroidsExercise routineOpiatesChiropractic treatmentMuscle relaxantAcupuncture381 (80)286 (61.1) 240 (50.4)155 (32.5)130 (27.3)111 (23.3)65 (13.7)30 (6.3)29 (6.1) 18 (3.8)116 (24.3)Hibbs et al4Hibbs 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 Scholar1,220 (symptoms)546 (treatments)Shoulder painLimb mobility decreasedJoint ROM decreasedRotator cuff syndromeBursitisArthralgiaFrozen shoulderPain in joint involving shoulder regionInjection site joint painStiffness shoulderShoulder bursitisInjection site joint movement impairment44.140.822.19.29.08.85.23.22.92.92.82.4Nonnarcotic analgesicsPhysical therapyCorticosteroid injectionHot and cold therapyOral steroidsNarcotic analgesicsHome shoulder exercisePain medication, not specifiedSurgeryMuscle relaxantsTopical analgesicsMassageChiropracticSlingAcupunctureShoulder manipulation with sedationAntibioticsMuscle stimulatorsOther254 (46.5)215 (39.4)109 (20.0)89 (16.3)79 (14.5)28 (5.1)19 (3.5)17 (3.1)16 (2.9)15 (2.7)10 (1.8)10 (1.8)7 (1.3)6 (1.1)4 (0.7)2 (0.4)2 (0.4)2 (0.4)41 (7.5)Not reportedRodrigues et al14Rodrigues 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 Scholar1Shoulder painLimited ROM100Ice packsPhysical therapyOral steroids1(100)Not reportedVeera et al20Veera S. Chin J. Kleyn L. Spinelli S. Tafler L. Use of osteopathic manipulation for treatment of chronic shoulder injury related to vaccine administration.Cureus. 2020; 12e9156Google Scholar1Shoulder painDecreased range of motionParesthesia100Osteopathic manipulative medicine under general anesthesiaAcupuncture treatmentsNonanesthetic osteopathic manipulationsPhysical therapy1 (100)1 (100)Wong et al30Wong W. Okafor C. Belay E. Klifto C.S. Anakwenze O. Arthroscopic surgical management of shoulder secondary to shoulder injury related to vaccine administration (SIRVA): a case report.J Shoulder Elbow Surg. 2021; 30: e334-e337Google Scholar1Shoulder painRotator cuff bursitisImpingement syndrome100Arthroscopic shoulder debridementSubacromial bursectomy1 (100)1 (100)Wright et al23Wright A. Patel R. Motamedi D. Influenza vaccine-related subacromial/subdeltoid bursitis: a case report.J Radiol Case Rep. 2019; 13: 24-31Google Scholar1Shoulder painSubacromial or subdeltoid bursitis100Steroid injection1 (100)1 (100)NSAID, nonsteroidal anti-inflammatory drug; ROM, range of motion. Open table in a new tab NSAID, nonsteroidal anti-inflammatory drug; ROM, range of motion. Ultimately, presentation will be related to the site of needle entry and the anatomic site of injury (Table 1). Systemic symptoms are uncommonly reported. However, they may rarely present secondarily to a disseminated infectious cause or in conjunction with an inflammatory reaction. Complex regional pain syndrome, though unlikely, may also be considered in patients where an underlying injury is not found and symptoms persist. Caution should be practiced when diagnosing complex regional pain syndrome. As an example, it was initially suspected that the human papillomavirus vaccine was associated with an increased risk of acquiring complex regional pain syndrome. This led to a temporary suspension of the vaccine in certain countries. It was later found that evidence supporting the association lacked significance, and the vaccine suspension was removed.21Huygen F. Verschueren K. McCabe C. et al.Investigating reports of complex regional pain syndrome: an analysis of HPV-16/18-adjuvanted vaccine post-licensure data.EBiomedicine. 2015; 2: 1114-1121Google Scholar For cases of persistent or worsening shoulder pain beyond 48 hours of vaccination, clinical evaluation may be warranted. The initial evaluation should consist of taking a history to correlate the symptoms to the injection, as well as to rule out other comorbidities or preexisting shoulder pathology. A physical examination of the shoulder should begin with inspection of the injection site. This is best done with full exposure of both shoulders, free of clothing, to maximize visualization and facilitate the evaluation of asymmetry, skin changes, or edema. Next, palpation of the site should be done gently, seeking to identify potential hematoma, fluctuance, abscess, or crepitus. Range of motion is initiated by first soliciting active range of motion by the patient in all planes of the shoulder. Typical range of motion of the shoulder includes forward flexion of 150° to 180°, extension of 40° to 60°, abduction of 150° to 180°, internal rotation to the thoracic spine, and external rotation of 60° to 90°.22Bakhsh W. Nicandri G. Anatomy and physical examination of the shoulder.Sports Med Arthrosc Rev. 2018; 26: e10-e22Google Scholar If active range of motion of the patient is abnormal, the shoulder can be passively manipulated to assess for maintenance of the full passive arc of shoulder motion. Next, strength testing can be undertaken, with particular attention being paid to the integrity of the deltoid function. This is achieved by testing the arm against resisted abduction (middle deltoid) and forward flexion (anterior deltoid). However, differentiating diminished strength from pain can be difficult and may warrant further evaluation with imaging.22Bakhsh W. Nicandri G. Anatomy and physical examination of the shoulder.Sports Med Arthrosc Rev. 2018; 26: e10-e22Google Scholar Finally, a thorough neurovascular examination should be done. Vascular injuries are not a recognized SIRVA complication and can be readily ruled out by palpating the brachial artery at mid-arm medially or the radial artery at the wrist volar-radially. Depending on the clinical concerns, a number of diagnostic studies are available to evaluate SIRVA. Radiographs (x-rays) are most readily available but will unlikely be positive or diagnostic early in the clinical course. If available, the imaging of choice would be magnetic resonance imaging (MRI), as it would provide the greatest detail of the typical pathologies associated with SIRVA, including hematoma, infection, subacromial bursitis, joint synovitis, adhesive capsulitis, and rotator cuff injury.23Wright A. Patel R. Motamedi D. Influenza vaccine-related subacromial/subdeltoid bursitis: a case report.J Radiol Case Rep. 2019; 13: 24-31Google Scholar In the majority of these injuries, contrast is unnecessary. However, MRI with contrast is recommended if an infection is suspected, as this will more clearly portray the amount of osseous and nonosseous involvement, and will establish the presence of tissue necrosis.24Towers J.D. The use of intravenous contrast in MRI of extremity infection.Semin Ultrasound CT MR. 1997; 18: 269-275Google Scholar If an MRI is not available, an ultrasound evaluation can also be considered and could provide clinical data for the same clinical diagnoses related to SIRVA.23Wright A. Patel R. Motamedi D. Influenza vaccine-related subacromial/subdeltoid bursitis: a case report.J Radiol Case Rep. 2019; 13: 24-31Google Scholar In cases of neurologic complaints consisting of pain, numbness, tingling, paresthesias, and weakness, an electrodiagnostic evaluation may also be warranted.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.Vacc
Referência(s)