What You Need to Know About SIRVA

Shoulder Injury Related to Vaccine Administration—SIRVA—is a very rare side effect associated with a shot being administered incorrectly.

Vaccines have been around for centuries. The first vaccine, which was for smallpox, was developed in the late 18th century, according to a journal article in Proceedings of the National Academy of Science. Even the flu vaccine has been around since 1942, according to the Centers for Disease Control and Prevention (CDC).

Many advances have been made in the effectiveness and safety of vaccines in general since their inception. But like any medication, vaccines can also have side effects. According to the CDC, some common ones are headache, fever, nausea, and muscle aches—and very rarely, allergic reactions, increased risk of certain conditions like Guillain-Barré Syndrome, and SIRVA—shoulder injury related to vaccine administration.

What Is SIRVA?

Ken Donohue, MD, a Yale Medicine orthopedic surgeon and shoulder specialist, explained to Health that SIRVA is a rare condition in which pain and loss of function in the shoulder occurs following a vaccination.

Just how uncommon is it? "I have seen very few cases of this in my patients as an orthopedic shoulder specialist," maintained Dr. Donohue. And because it is so rare, there is little information available about it. Some medical professionals even deny its existence.

For example, in a 2022 review of the literature published in the journal Clinical Orthopaedics and Related Research, study authors noted that the National Academy of Medicine's Committee on the Adverse Effects of Vaccines' position on SIRVA is that there is no question that the evidence confirms that injectable vaccines can cause deltoid (shoulder muscle) bursitis.

But these study authors also note that the American Academy of Orthopaedic Surgeons (AAOS) has published two positions on this topic, first in 2017 and again in 2020, stating that there is no evidence that vaccines cause any injuries to the shoulder.

Other reviews seem to favor the National Academy of Medicine's position, though. For example, a 2022 review of the literature published in the journal Clinical Orthopaedics and Related Research stated that based on the studies they reviewed, though "exceedingly rare," about one out of 130,000 vaccinations results in SIRVA.

Another 2022 literature review published in the journal Vaccine stated that "SIRVA is an increasingly recognized complication after vaccination" and suggested that risk factors for SIRVA include female gender, a thin physical build, a smaller deltoid muscle, and improper injection techniques.

Even the US Department of Health and Human Services agrees that SIRVA is a real thing. In an "Update on SIRVA" document, they stated that "The Institute of Medicine (IOM) reviewed the scientific and medical literature finding that the evidence convincingly supported a causal relationship between vaccine administration and deltoid bursitis."

What Causes SIRVA?

Dr. Donohue explained that while doctors and nurses are properly trained in using the proper needle length and landmarking—determining where a vaccine should be given in the arm—sometimes the injection is not placed where it should be. "When a needle is injected too deep, the deltoid muscle can be penetrated and structures within the shoulder can be damaged, such as the rotator cuff or joint capsule," explained Dr. Donohue. In very rare cases the axillary or radial nerves in the upper arm could be injured.

A 2018 study published in the Canadian Pharmacists Journal specified that SIRVA "occurs when an injection is administered too high in the arm, and the vaccine is delivered to the shoulder capsule instead of the deltoid muscle." These study authors also stated that injecting into the wrong part of the arm initiates an inflammatory response, which damages structures in the shoulder—like tendons and bursa.

Symptoms and Treatment of SIRVA

While dull muscle ache pain after a vaccine injection is common, it usually disappears on its own within days. With SIRVA, an individual will usually start feeling pain within 48 hours of the vaccination, and the pain doesn't improve over time.

"In patients who experience SIRVA, months may pass by, and patients will still complain of increasing pain, weakness, and impaired mobility in the injected arm. Simple actions like lifting your arm to brush your teeth can cause pain," said Kelly Grindrod, PharmD, a professor in the School of Pharmacy at Waterloo and one of the authors of the 2018 study.

According to the 2022 review in Clinical Orthopaedics and Related Research, the most common symptoms of SIRVA are shoulder pain and reduced range of motion. And the most common diagnoses tend to be shoulder bursitis, adhesive capsulitis (aka frozen shoulder), and rotator cuff tears.

People experiencing these symptoms should talk to their doctor. "It's important that we learn to recognize these signs of SIRVA so that we can access appropriate treatment," added Grindrod.

To diagnose SIRVA, an ultrasound scan or MRI is needed, which can also determine the level and type of damage, per a 2022 study in the Canadian Medical Association Journal. Common treatments for SIRVA include lifestyle and work modifications, non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy. If these conservative treatments don't work, corticosteroid injections may help, and surgery may be the solution in more severe cases.

Prevention of SIRVA

Most importantly, healthcare providers who administer vaccinations need to use proper vaccination landmarking techniques, according to Grindrod. However, if you are the one getting vaccinated, there are a few precautions you can take.

"It's important to let the people administrating vaccinations see the entire shoulder so that they can reference the necessary landmarks for proper injection," said Dr. Donohue. "Wear a sleeveless shirt or shirt that can be removed in order to reveal the entire shoulder. Rolling up the sleeve may prevent the person administering the vaccine from seeing all of the landmarks necessary to administer appropriately."

The small risk of SIRVA shouldn't be a reason to avoid vaccinations that could potentially save your life. "I can't emphasize enough that the risks associated with not being vaccinated far outweigh the possibility of SIRVA," said Dr. Donohue. "My advice is to still be vaccinated as you normally would but to talk to your primary care doctor about any concerns you may have."

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