What is SIRVA?

If you’ve landed on this website, maybe it’s because you went in for a vaccination, you were surprised to find yourself still in pain more than 3 days later, and you searched for information about why your shoulder still hurts. I did a lot of that in the days and weeks after my flu shot, when it became obvious that the usual soreness should have passed already. Then I learned about SIRVA.

There are a few articles about Shoulder Injury Related to Vaccine Administration (SIRVA) in newspapers and in peer-reviewed scientific journals. I have provided links to those on the Resources page, and will continue to update that page whenever new articles come out. This post is my summary of that information, after reading and poring over everything I could find. If there’s something medically incorrect here, please, correct me in the comments! I am not medically trained, although I am a scientist and can distinguish between reliable and unreliable sources of information.

Anyway, welcome to this website, and please leave a comment to say “hi” and tell me what you know about SIRVA. If you have SIRVA, please consider taking the SIRVA Survey! It’s private and anonymous. Only by gathering more information can we begin to understand this condition better, together.

What’s going on in my shoulder?

SIRVA is thought to be an immune response to the active agents in the vaccine, which results in inflammation, excess fluid where it doesn’t belong (bursitis), and potentially (in the worst cases) even more damaging effects to the tendons and bone. These features are often visible on MRI and ultrasound imaging, although bursitis and other tendon issues may have pre-existed before your vaccine but were previously not causing you any pain.

With the added inflammation and fluid often comes impingement, which is when certain things get pinched in the tight shoulder joint. Before your SIRVA started, you probably had just the right amount of space for all the bones, tendons, nerves, etc. in your shoulder joint. Now, the fluid and inflammation take up extra space and stuff starts rubbing wrong. It results in the sharp pain you’re feeling on certain movements. Frozen shoulder is also sometimes an associated side effect of SIRVA.

What causes SIRVA?

By this point in time, it SHOULD be well known in the medical community that injecting a vaccine too high on the shoulder will put it into the bursa space (subdeltoid or subacromial) or other part of the shoulder where it doesn’t belong. However, many people who are trained to give the shot are unaware of the dangers (50% in one study). SIRVA can be caused by any vaccine, but it is thought that having previously received at least one dose of the same vaccine increases the risk.

The difference between a properly administered shot (in the deltoid muscle) and improperly administered is that the muscle is highly “vascular” (good blood flow) and the vaccine is designed for that system. In your bursa, in your shoulder joint, it is far less vascular and the body isn’t prepared to deal with the highly “immunogenic” agents in the vaccine. So it fights it, but unlike your body fighting it safely in the muscle, it leads to the undesired symptoms and potential damage described above.

What can I do about it?

Because there are several ways SIRVA manifests in the body, there are multiple possible ways to approach treatment. I can’t tell you what will be effective in (a) reducing your pain or (b) hastening recovery to full shoulder health. I will tell you what I’ve tried, and if you fill out the SIRVA Survey, I will let you know what has worked for other people in future blog posts!

Anti-inflammatories: You might want to start these, if you haven’t already (UPDATE: I’m not sure THAT was good advice, I took them for months before hearing the opinion that they can potentially block the appropriate signals your body sends to injured areas. My primary care doctor and first orthopedist recommended them, but my current doctor doesn’t. Consult your doctor.) Because of the strong inflammation component of SIRVA, they are likely to help cut the pain (UPDATE: but maybe not promote healing). I chose Aleve (naproxen) over Advil (ibuprofen), because I’ve previously found it works better for me (I don’t know why).

Ice: A lot of people recommended icing for 20 minutes 3 times a day. As SIRVA drags on for a while, that becomes pretty difficult to do every day (for me anyway), but I try to apply ice after doing anything that aggravates the shoulder or causes pain. I don’t notice that it makes any difference.

Physical therapy: Frozen shoulder is a common outcome of SIRVA, so getting on top of PT soon is a good idea. It can also help a lot with some associated imbalances and tension that may occur from using your painful shoulder. I don’t know if it’s helpful by itself, given the biochemical nature of SIRVA, but it’s worth a try. Unfortunately, there is probably not one standard way a PT will approach SIRVA cases, with so little information out there. There are standard approaches for subacromial bursitis and for frozen shoulder.

Cortisone shot: You might be reluctant to get another shot when your whole problem was caused by a shot in the first place. I was. But some people find relief, or even complete recovery from SIRVA symptoms (!), from cortisone injections. I had high hopes for this and was disappointed to find absolutely no improvement in my case, and there are possible negative side effects of cortisone shots themselves. In consultation with your doctor, you should consider it, but be prepared (emotionally) for either outcome. I have heard it said that you should see an orthopedist for your cortisone shot and not your primary care doctor (to ensure accurate placement).  Some doctors will even do ultrasound-guided cortisone injection, but mine didn’t.

Rest: Unfortunately, this is the one everyone recommends: I have heard from multiple medical practitioners that you should avoid doing the motions that hurt or aggravate your symptoms. For me, that’s rock climbing, my absolute favorite thing on the planet to do, but for you it might be swimming, tennis, reaching for things, whatever. I wish I could do a controlled experiment where I kept rock climbing in one case and rested in another, and see if it makes a difference (since it is a chemical response), but I didn’t want to risk it.

Here’s a random picture of me climbing, long before the SIRVA incident.

Running: One doctor theorized that running might help, since it involves pumping the arms (encourages fluid movement in the joint) without overhead motions. If it hurts, don’t do it, but if it doesn’t hurt, maybe it’s worth a try. I’m going to give a go, even though I don’t enjoy running very much.

What does the CDC have to say about SIRVA?

The Code of Federal Regulations (CFR), Title 42, Part 100, discusses recognized injuries from vaccines and the compensation that sufferers are eligible for. SIRVA is defined there as:

(10) Shoulder injury related to vaccine administration (SIRVA). SIRVA manifests as shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm. These symptoms are thought to occur as a result of unintended injection of vaccine antigen or trauma from the needle into and around the underlying bursa of the shoulder resulting in an inflammatory reaction. SIRVA is caused by an injury to the musculoskeletal structures of the shoulder (e.g. tendons, ligaments, bursae, etc.). SIRVA is not a neurological injury and abnormalities on neurological examination or nerve conduction studies (NCS) and/or electromyographic (EMG) studies would not support SIRVA as a diagnosis (even if the condition causing the neurological abnormality is not known). A vaccine recipient shall be considered to have suffered SIRVA if such recipient manifests all of the following:

(i) No history of pain, inflammation or dysfunction of the affected shoulder prior to intramuscular vaccine administration that would explain the alleged signs, symptoms, examination findings, and/or diagnostic studies occurring after vaccine injection;

(ii) Pain occurs within the specified time-frame;

(iii) Pain and reduced range of motion are limited to the shoulder in which the intramuscular vaccine was administered; and

(iv) No other condition or abnormality is present that would explain the patient’s symptoms (e.g. NCS/EMG or clinical evidence of radiculopathy, brachial neuritis, mononeuropathies, or any other neuropathy).

The CDC is well aware of SIRVA (e.g., presentation pdf), but avoids mentioning it on its pages about possible vaccine complications (e.g., here). A lack of knowledge about the problem, even among health care providers, contributes to its ongoing recurrence. Please write the CDC, everyone, and encourage them to take further steps in promoting good practices for administration of vaccines.  If you have ideas about how else to get the word out, please let me know!

 

6 thoughts on “What is SIRVA?”

Leave a Reply

Your email address will not be published. Required fields are marked *