It depends on person and probably countries whether people receive a vaccine every year. I personally had had a flu vaccine every single year until 5 years ago. Vaccine has now become mandatory for most people to mitigate the risk of a fatal event. Vaccine can cause some musculoskeletal issues. We will likely have had the third jab (the booster shot) in the near future. Therefore, it may be rare, yet it is vital for clinicians to know if a patient with shoulder pain is possibly caused by vaccine. This vaccine is not only COVID-19 one but also influenza, tetanus, diphtheria, pneumococcal conjugate, pneumococcal polysaccharide, hepatitis, mumps and rubella [5].
Shoulder pain is a common side effect of having vaccination. Muscle soreness or shoulder pain after the vaccination goes away within 2-3 days [1].
What is common presentation after the vaccination? [1,2].
· Mild and transient local pain, redness, swelling, soreness resolve within 2-3days after the vaccination
· Symptoms above occur on the same side you had a vaccine
· No movement loss present
When do we suspect a possible injury or condition?
·Severe pain following vaccine administration, pain can occur 18days after the vaccine administration [10].
· Sleep disturbance due to pain
· NSAIDs does not improve pain
· Weakness, numbness and tingling
· Limited ROM (Range of Motion)
· New episode of shoulder pain
Possible injuries after the vaccine
·SIRVA (shoulder injury related to vaccine administration)
·Parsonage turner
·Adhesive capsulitis (frozen shoulder)
· Bursitis (subdeltoid, subacromial)
· Rotator cuff tendinopathy
· Biceps tendinopathy
· Glenohumeral effusion [2]
SIRVA (shoulder injury related to vaccine administration)
This is the term about shoulder pain post-vaccine administration due to inflammation, resulting in shoulder injuries such as frozen shoulder and bursitis. This occurs when the vaccine inserts into the bursa (sub-deltoid or subacromial) [2,3]. This can happen after an influenza and COVID-19 vaccine [1, 3, 4].
Other injections site events
When the injection hits the nerve, you may feel shooting pain during administration and weakness and numbness after the injection [2, 3].
*SIRVA indicates that shoulder injury is caused by the needle inserted in the shoulder joint or the bursa whereas nerve injury due to injection is classified as other injections site events.
Rotator cuff tendinopathy and Bursitis [5, 6]
The common initial diagnosis by practitioners and MRI findings are the rotator cuff pathologies (tendinopathy) and bursitis. Patients often complain of tenderness upon palpation and limited ROM. The age group that was present with shoulder pain the most was age 18-49 followed by age group 50-64 [5, 6].
How do we possibly differentiate the post-vax rotator cuff pathology from different rotator cuff pathology?
When a patient comes in with shoulder pain, what leads you to suspect the rotator cuff pathologies? What question would you ask to rule in the rotator cuff tendinopathy?
Main different is that degenerative rotator cuff tear is often seen age over 60 while post-vax rotator cuff pathology (tendinopathy) is seen younger age group [7, 8]. If no clear mechanism that has potentially caused rotator cuff pathology, but pain or symptoms started after they had a vaccine, it may lead you to suspect rotator cuff pathology due to vaccine.
Rotator cuff tear risk factors [7. 9]
· Age over 60
· Overweight BMI
· Hypertension
· Diabetes
· smoker
· Dominant hand
· Overuse
Understand the tendon pathology
Understand the tendon pathology and recovery phase (inflammation, time etc…)
Tendon pathologies can be classified into 3stages. Reactive tendinopathy is an acute phase of the tendon pathologies that are present with inflammation. Pain becomes worse in the night time due to increase in cytokine. In the phase of the tendon disrepair, increase in chondrocytes, fibroblasts and new blood vessel growth are seen to restore. Degenerative tendon is the last phase of healing process in tendon. In this phase, tendon might not have been loaded enough or may be torn [9].
Rotator cuff tendinopathy post vaccine may go through different healing process as it is associated with inflammation.
What can we do?
If it is acute phase, it may be challenging to identify what the problem is. Patients are often present with pain and restricted ROM. Therefore, a focus and goal setting should be a reduction of pain, improvement in ROM and explanation of pathology and prognosis (reassurance).
Parsonage-turner syndrome (PTS)
Parsonage-turner syndrome (PTS) also called neuralgic amyotrophy is a rare condition of peripheral nerve injury [10]. There are some cased reported of PTS after COVID-19 vaccination (Pfizer, AstraZeneca and Moderna) [10, 11, 12]. One or more of the peripheral nerves such as the suprascapular, dorsal scapular, musculocutaneous, axillary, radial, long thoracic and ulnar nerve (rare) can be affected. It is also reported that PTS can cause a phrenic nerve dysfunction after PTS, presenting with shortness of breath, sleep disorder and difficulty in breathing [11].
Pain lasts for 4 weeks on average followed by neurological symptoms such as weakness, numbness and sensory loss.
To identify, CT, MR neurography and EMG can be used but not nerve conduction studies [10, 11, 12].
Signs and symptoms
· Sudden onset (wake up with severe pain)
· Symptoms can occur in the contralateral (opposite) shoulder
· Neurological symptoms (numbness, weakness) after pain has subsided
Oral prednisone may be helpful for PTS [10].
Adhesive capsulitis (frozen shoulder)
Although the adhesive capsulitis is not prevalent post vaccination, it can be seen.
Risk factors of frozen shoulder are age 40-60, diabetes, thyroid disease, cerebrovascular disease, coronary artery disease, autoimmune disease and female [15]. If the condition is acute, limited ROM may not be present. Pain is severe and affects sleep at the early stage before seeing loss of motion.
When you suspect that a patient has the early stage of the frozen shoulder, corticosteroid injection is recommended [13, 14].
What is relevant to myotherapists and what can we learn from shoulder injury after vaccination?
Vaccine administration is not myotherapist’s scope of practice. Then, can we learn something from this?
-When perform dry needling-
·Choose an appropriate side of needles on each individual to avoid shoulder injury
·Sanitise to avoid infection
-Goal settings-
·Manage and reduce pain level by reassurance and interventions
·Keep patients active to restore ROM
Pain and loss of ROM are the common presentations of shoulder pathology post-vaccination.
It is vital for practitioners to keep patients active to restore ROM as if they do have shoulder pathology due to vaccine, it may take some time to regain full ROM. It is not common and not easy to pick this up yet important to keep that in mind if pain and loss of motion occurs after vaccination.
References
[1] Chuaychoosakoon, C., Parinyakhup, W., Tanutit, P., Maliwankul, K., & Klabklay, P. (2021). Shoulder injury related to Sinovac COVID-19 vaccine: A case report. Annals of Medicine and Surgery, 68, 102622. https://doi.org/10.1016/j.amsu.2021.102622
[2] Shahbaz, M., Blanc, P. D., Domeracki, S. J., & Guntur, S. (2019). Shoulder Injury Related to Vaccine Administration (SIRVA): An Occupational Case Report. Workplace Health & Safety, 67(10), 501–505. https://doi.org/10.1177/2165079919875161
[3] Bancsi, A., Houle, S., & Grindrod, K. A. (2019). Shoulder injury related to vaccine administration and other injection site events. Canadian family physician Medecin de famille canadien, 65(1), 40–42.
[4] Cantarelli Rodrigues, T., Hidalgo, P. F., Skaf, A. Y., & Serfaty, A. (2021). Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA). Skeletal Radiology, 50(11), 2293–2297. https://doi.org/10.1007/s00256-021-03803-x
[5] Hesse, E. M., Atanasoff, S., Hibbs, B. F., Adegoke, O. J., Ng, C., Marquez, P., Osborn, M., Su, J. R., Moro, P. L., Shimabukuro, T., & Nair, N. (2020). Shoulder Injury Related to Vaccine Administration (SIRVA): Petitioner claims to the National Vaccine Injury Compensation Program, 2010–2016. Vaccine, 38(5), 1076–1083. https://doi.org/10.1016/j.vaccine.2019.11.032
[6] Hibbs, B. F., Ng, C. S., Museru, O., Moro, P. L., Marquez, P., Woo, E. J., Cano, M. V., & Shimabukuro, T. T. (2020). Reports of atypical shoulder pain and dysfunction following inactivated influenza vaccine, Vaccine Adverse Event Reporting System (VAERS), 2010–2017. Vaccine, 38(5), 1137–1143. https://doi.org/10.1016/j.vaccine.2019.11.023
[7] Sayampanathan, A. A., & Andrew, T. H. C. (2017). Systematic review on risk factors of rotator cuff tears. Journal of Orthopaedic Surgery, 25(1), 230949901668431. https://doi.org/10.1177/2309499016684318
[8] Sambandam, S. N. (2015). Rotator cuff tears: An evidence based approach. World Journal of Orthopedics, 6(11), 902. https://doi.org/10.5312/wjo.v6.i11.902
[9] Kaplan, K., Hanney, W. J., Cheatham, S. W., Masaracchio, M., Liu, X., & Kolber, M. J. (2018). Rotator Cuff Tendinopathy: An Evidence-Based Overview for the Sports Medicine Professional. Strength & Conditioning Journal, 40(4), 61–71. https://doi.org/10.1519/ssc.0000000000000364
[10] Queler, S. C., Towbin, A. J., Milani, C., Whang, J., & Sneag, D. B. (2022). Parsonage-Turner Syndrome Following COVID-19 Vaccination: MR Neurography. Radiology, 302(1), 84–87. https://doi.org/10.1148/radiol.2021211374
[11] Crespo Burillo, J., Loriente Martínez, C., García Arguedas, C., & Mora Pueyo, F. (2021). Amyotrophic neuralgia secondary to Vaxzevri (AstraZeneca) COVID-19 vaccine. Neurología (English Edition), 36(7), 571–572. https://doi.org/10.1016/j.nrleng.2021.05.002
[12] Diaz‐Segarra, N., Edmond, A., Gilbert, C., Mckay, O., Kloepping, C., & Yonclas, P. (2021). Painless idiopathic neuralgic amyotrophy after COVID ‐19 vaccination: A case report. PM&R. Published. https://doi.org/10.1002/pmrj.12619
[13] Koh, K. (2016). Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Medical Journal, 57(12), 646–657. https://doi.org/10.11622/smedj.2016146
[14] Ahn, J. H., Lee, D. H., Kang, H., Lee, M. Y., Kang, D. R., & Yoon, S. H. (2017). Early Intra-articular Corticosteroid Injection Improves Pain and Function in Adhesive Capsulitis of the Shoulder: 1-Year Retrospective Longitudinal Study. PM&R, 10(1), 19–27. https://doi.org/10.1016/j.pmrj.2017.06.004
[15] Le, H. V., Lee, S. J., Nazarian, A., & Rodriguez, E. K. (2016). Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments. Shoulder & Elbow, 9(2), 75–84. https://doi.org/10.1177/1758573216676786
