Age: 71.0
Sex: M
Vaccine: UNK
Symptoms: Iliotibial band syndrome, Impaired driving ability, Insomnia, Ligament pain, Loss of personal independence in daily activities
Clinical narrative: He got his vaccine, started out with very severe pain in the left shoulder, arthritic type pain in the shoulder joint and in his neck joint as well, extremely severe.  He felt he had slipped a disc or broken one late at night and hurt so bad that he felt that he could not drive to go to the ER.  It moved down his body during the night, moved to hip joint, knee joint and muscles, tendons and ligaments in his foot.  He has an IT band problem, and the IT band started contracting and would do so intermittently to the point that it was too painful to stay in the bed.  He still cannot sit down for very long as if he bends his left leg at all it starts really really hurting, and has not been able to sleep even with all the medicines described.  This went on for several days, and had an old prescription for opioids and read that after 4 days it would go away and it did not.  It was especially bad at night.  The only way he feels comfortable with his knee, foot and leg if he walks for about an hour and gets some calming effect but pain has not been gone.  This has been going on for several weeks, has worn him out as he cannot sleep.   He has not been able to go to his fitness classes which helps with his chronic pain, and not been able to socialize due to the pain.  He is still having pain now.  His doctor is referring him to a rheumatologist, but that may take a while.  After the initial 4 days he decided to go to the ER as he ran out of his prescription of medicine that he had.  He went to minor ER and gave him a shot of Toradol and muscle relaxers.  He went to another ER and they only had a NP on call.  He then went to second ER they felt that he was drug seeking, as he was not writhing in pain they felt he was faking it.   He then went to his PCP and he told him that he basically has a substance abuse problem, and changed physicians.  She had seen his reactions as one of the nurses had the same reaction and she prescribed Tylenol #3, which has not taken away the pain, Meloxicam, Tizanidine 4 mg every 6-8 hours, Pregabalin and upped to 150 mg.  The pain is receding somewhat, somewhat in his leg, but still very severe in his leg, shin and the top of his left foot.   It is in the area of the neuroma, but not too bad.  It has also caused what feels like holes or tears in his muscles which when he touches them are excruciating in the front of his leg quad muscles feels like a sore place, also his lower left calf there is a pretty bad place and behind his left knee.  His whole shin under the left shin is bruised to the point that they had turned purple.  The leg is still somewhat red.  He never had problems in the arm itself.    He has had problems with his leg prior to the vaccine, IT band pain due to severe sciatica, but the vaccine exacerbated the pain and created an acute severe arthritis.    It is not as severe right now, but is only about to get 4-5 hours of sleep max due to the pain.  He is not able to get out and about, having depression due to being trapped in his house due to the discomfort and pain.