Initial case was retrieved from the scientific literature on 27 November 2012. The following was copied verbatim from the literature case: "A 22-year-old woman with a weight of 120 lbs (54 kg) and no significant prior medical history presented with acute left shoulder pain, which limited her range of motion and functional ability. The patient was in her usual state of health until she received the influenza vaccine approximately 2 months before initial presentation. The 2011 seasonal flu vaccine was given by a trained medical technician, who reported placing the vaccine "3 fingers from the acromion" (measured at 2.75 inches or approximately 7 cm) in the middle of the deltoid, "hubbing" (inserting the needle to the depth of the plastic hub but not depressing surrounding skin) a 1-inch, 23-gauge needle, and injection the vaccine. The patient reported having the onset of shoulder pain at the administration site within 2 hours of vaccination. Over the next 6 weeks, she had progressive limitations of her range of motion of her left shoulder and increasing pain, 9 out of 10 pain on a pain scale. On examination, the patient had very limited range of motion and experienced pain with both active and passive range of motion. Plain radiographs were unremarkable. Ultrasound imaging, at 9.5 weeks after the initial injection, demonstrated a partial tear of the supraspinatus tendon as well as cortical irregularity on the superolateral humeral head at the point of injection. MRI, at 8 weeks after the initial injection, showed joint effusion in the subacromial bursa, a longitudinal partial tear of the supraspinatus tendon, and a consistent bony contusion. Due to her limited range of motion, the patient had an immediate referral to sports medicine and was referred for aggressive physical therapy. A report of this patient's history was sent to the Vaccine Adverse Event Reporting System. At 11 weeks after initial presentation, the patient was re-evaluated and found to have significant improvement in pain (1 out of 10) at rest, reporting discomfort with use of the left shoulder but no limitations in function. Ultrasound images at that time demonstrated residual fluid at the supraspinatus with a consistent cortical irregularity. In follow-up with the patient, at 16 months after the initial injection, she reports that her range of motion and strength continue to allow her to conduct all her desired daily activities. This patient developed signs and symptoms consistent with previously described cases of shoulder injury related to vaccine administration (SIRVA) in the literature. The patient was female, previously exposed to the influenza vaccine, and developed multiple shoulder injuries almost immediately after vaccine administration. The authors of these case series suggested that SIRVA is due to an inflammatory effect from vaccine administration into the subdeltoid bursa. This inflammatory response may be due either to the antigenic or nonantigenic components of the vaccine (antimicrobial, preservative, etc). They based these assumptions on the consistent presentation of adhesive capsulitis (as demonstrated by the patient's pain, lack of motion, weakness, and impaired mobility/functionalitiy) and multiple noted pathologies on imaging, more than would be expected by the trauma of vaccination. Previously, there was only a single documented case of bone friability in SIRVA. This current case has a previously unreported finding of persistent cortical irregularity, making a stronger case for the inflammatory response of the vaccine as the pathogenic factor of SIRVA." The patient's outcome was not reported. Documents held by sender: none.