Age: 54.0
Sex: F
Vaccine: FLU4
Symptoms: Injected limb mobility decreased, Injection site pain, Injection site reaction, Joint debridement, Joint noise
Clinical narrative: When receiving influenza vaccine at workplace clinic on 9/14/2018, no unusual pain was noted at the time of injection, however, the nurse administering the vaccine noted that it was "hard to inject". Pain was noted later in the afternoon, similar to other previous vaccines, however, difficulty raising arm above shoulder level was also experienced. Symptoms initially improved after 36 hours, then worsened after the subsequent week and the injury was reported to the Health at Work office. Pain, strength and range of motion (ROM) continued to worsen, in spite of increasing doses of ibuprofen to 600mg every 6 hrs (unable to tolerate this dose for long due to GI symptoms). Referral was made to orthopedic surgeon with the following treatments: o Tramadol 50 mg at bedtime as needed (used intermittently since 10/5/2018) o Flexeril 5mg at bedtime as needed (used intermittently since 10/5/2018) o Acetaminophen 1g 2-3 x/day (intermittently prior to surgery, daily through March 2019, currently as needed) o Diclofenac gel topically twice daily (10/2018  ongoing, as needed) o Meloxicam 15mg (11/14/2018-ongoing)  now on 7.5mg daily since 3/19/2019 o Steroid injections x 2: 10/5/2018 (relief of pain x 2 days, improved ROM x 6 days) and 11/14/2018 (decrease in pain, but not eliminated) o Physical therapy twice weekly (10/10/2018  11/6/2018 and 1/15/2019  4/15/2019)  exercises, myofascial release, iontophoresis (total of 6, last done in January), TENS/IFT, dry needling, kinesiology taping, joint mobilization, ultrasound x1 o Application of cold packs 2-3 times daily (October-February; currently as needed) o 1/3/2019 - arthroscopic shoulder surgery at Hospital  left shoulder arthroscopic debridement foreign body bursitis and partial-thickness rotator cuff tear; left shoulder subacromial decompression. Initial course following vaccination: Periods of slight improvement followed by worsening episodes, unrelated to activity, etc. Worsening episodes associated with increased pain, sensation of feeling hot (without fever) and popping/crunching in the joint. Resting pain was as low as 1-2/10, up to 6/10; most days had constant resting pain. Frequent sharp pains (7/10) with almost every arm movement. Multiple distinct areas of pain involving shoulder (anterior and posterior), various locations on the upper arm and extending to the elbow, as well as subscapularis region. Minimal impact at work, mostly sedentary deskwork as Clinical Research Nurse. Significant impact on ADLs including cooking, cleaning, laundry, grocery shopping, driving/travel and sleeping  improved by mid-late February 2019. After initial post-op period, had gradual improvement in pain and function. By late February, ROM and strength almost back to normal but have continued to have persistent, intermittent episodes of pain with movement as well as pain at rest, lasting 1-6 hrs; occasional days with little to no pain. Released by surgeon on 4/10/2019 with a permanent partial disability rating of 10% for the left upper extremity.