Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pain in extremity, Periarthritis, Rotator cuff syndrome, Shoulder injury related to vaccine administration
Clinical narrative: I received my second Moderna Covid-19 vaccine shot on March 28, 2021.  The shot was injected high up on my arm at the curve of my shoulder.  Approximately 3 hours later, while sitting on my couch watching television, I began to experience significant pain in my upper left arm, shoulder and, to a lesser degree, my forearm just below the elbow.  The pain was so severe, I could not lift my arm without assistance from my opposite hand.  The severe pain lasted about 3 days, then began to slightly subside.  The pain leveled out at approximately a 6-7 out of ten, about 4-5 days post injection.   After about 9-10 days, I made an appointment with my PCP and after a week or two of taking Ibuprofen with little to no improvement, I requested physical therapy.  I began my course of PT on April 19, 2021.  At my first visit, I explained my symptoms to my physical therapist and he asked me if I had ever heard of SIRVA.  It was his opinion that I had absolutely suffered an injury from the injection and diagnosed me with SIRVA.  I have now been treating for over 6 months and although I have had some improvement, I often regress for several days to weeks at a time when trying to add exercises that involve even the slightest amount of weight; i.e., 1-2 pounds.  In addition, one area of my upper arm continues to experience significant pain with certain movements and I can still experience levels of pain ranging from 4-7, depending on the movement.  I also saw a physiatrist on May 24, 2021 who, upon examination, advised me that I was presenting with symptoms of a rotator cuff injury.  My physical therapist and I have discussed the possible need for an MRI at this time.  On October 5, 2021, I had an MRI of my left shoulder which revealed:  1) Moderate anterosuperior rotator cuff tendinosis with high-grade undersurface tearing of the supraspinatus tendon extending into the anterior fibers of the infraspinatus tendon, as described.  2) Moderate acromioclavicular joint osteoarthritis and mild subacromial/subdeltoid bursitis. 3) Small subacromial spur. 4) Thickened edematous inferior joint capsule, and infiltration and edema within the rotator interval fate, findings that can be seen in adhesive capsulitis (frozen shoulder).  On October 28, 2021, I followed up with an orthopedic surgeon.  After physical examination and reviewing the results of the MRI, it was his opinion that my frozen shoulder was the main cause of the pain, reduced range of motion and reduced strength I am experiencing.  I received a cortisone shot in my shoulder and it was his hope that my symptoms would subside; however, he advised that he expected my recovery time to be between 18 months and 2 years.  At this time, I continue to have reduced range of motion, reduced strength and pain with certain movements of my left arm.  I also experience achiness and/or pain at rest on occasion.  I am still unable to extend my left arm straight up over my head, the elbow remains somewhat bent and my right arm extends approximately 3 inches above my left.  I cannot reach straight out to the side and lift my arm, with or without holding anything.  I am also unable to reach behind me to retrieve an item, nor am I able to reach behind my back to adjust clothing or scratch my back.  I am also restricted from laying on my stomach and being able to place my left arm straight, extending above my head (as in yoga's child pose), or extend it straight out to the side.  All of these motions cause pain, sometimes significant, and discomfort.  Although the doctor is hopeful for full recovery, due to my slow progress and many regressions, I am not totally convinced that this will be the case.  It is my understanding that at times, this type of injury does not fully resolve.  Only time will tell.  I am currently continuing with a home exercise program and following up with my physical therapist on a monthly basis.