Elsevier

Vaccine

Volume 25, Issue 4, 8 January 2007, Pages 585-587
Vaccine

Short communication
Vaccination-related shoulder dysfunction

https://doi.org/10.1016/j.vaccine.2006.08.034Get rights and content

Abstract

We present two cases of shoulder pain and weakness following influenza and pneumococcal vaccine injections provided high into the deltoid muscle. Based on ultrasound measurements, we hypothesize that vaccine injected into the subdeltoid bursa caused a periarticular inflammatory response, subacromial bursitis, bicipital tendonitis and adhesive capsulitis. Resolution of symptoms followed corticosteroid injections to the subacromial space, bicipital tendon sheath and glenohumeral joint, followed by physical therapy. We conclude that the upper third of the deltoid muscle should not be used for vaccine injections, and the diagnosis of vaccination-related shoulder dysfunction should be considered in patients presenting with shoulder pain following a vaccination.

Section snippets

Case 1

A healthy 71-year-old woman received a pneumococcal vaccine injection (Pneumovax, Merck) high into the right deltoid muscle at a local pharmacy. Within 2 days her shoulder began to hurt and she had difficulty moving her arm. She took a dose of acetaminophen and a dose of ibuprofen with no relief. She saw her family physician, who diagnosed her with subacromial bursitis. She declined a corticosteroid injection and was referred to physical therapy.

Five months later she continued to have shoulder

Case 2

A healthy 89-year-old man was provided with an influenza vaccine injection (Fluzone, Aventis Pasteur) high into the right deltoid muscle by a visiting health care worker. Within 2 days, he experienced severe right shoulder pain and loss of range of motion. Although he had experienced some mild occasional shoulder pain in the past, he never had severe pain or loss of range of motion.

He took acetaminophen to relieve some of his pain, but did not seek medical help until 2 months later when he

Discussion

In comparing the two cases, we note some interesting similarities. First of all, both patients reported receiving injections high into the deltoid muscle, within a centimeter or two of the acromion.

We researched the length and type of needles used, noting them to be 1 in. (2.5 cm) and #23 and #25 gauge. Then using 8–16 MHz ultrasound (Diasus, Dynamic Imaging), we measured how far the subdeltoid bursa extended distally from the acromion in each patient, noting this to be 3.5 cm for our female and 4.0 

Acknowledgement

We thank Noel R. Rose MD, Ph.D. and Clifford Lowell MD for discussing the plausibility of our hypothesis and advising us in our literature review.

References (3)

There are more references available in the full text version of this article.

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    Further research, including population-level epidemiological data, is needed to elicit reasons behind this imbalance. While we did not collect data on the needle type used, other studies have suggested that using the incorrect needle type for that patient can increase the risk of overpenetration and SIRVA, as can failing to account for individual patients' anatomical landmarks.[2,3,8,17] As in existing literature, we found that SIRVA was most common after the influenza vaccine.

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    Overpenetration has been implicated as the largest contributing factor to development of SIRVA, though correct technique also plays an important role [5]. The subdeltoid bursa is located between 0.8 cm and 1.6 cm below the skin surface, a distance easily penetrable by the standard 1-inch (25 mm) needle [25]. It is well-documented in the literature that a one-size-fits-all approach should not be uniformly applied to all adult deltoid IM vaccinations [26–28].

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