Court Opinion

ID: 6319989
Source: CourtListenerOpinion
Date Created: 2022-03-03 22:01:52.087082+00
Date Added: 2024-06-11T09:02:35.453355
License: Public Domain

In the United States Court of Federal Claims
                                 OFFICE OF SPECIAL MASTERS
                                         No. 19-0109V
                                        UNPUBLISHED

    CHRISTINE HEIL,                                         Chief Special Master Corcoran

                        Petitioner,                         Filed: January 25, 2022
    v.
                                                            Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                 Findings of Fact; Onset; Statutory
    HUMAN SERVICES,                                         Six-Month Requirement; Influenza
                                                            (Flu) Vaccine; Ruling on Entitlement;
                       Respondent.                          Table Injury; Shoulder Injury Related
                                                            to Vaccine Administration (SIRVA)

Scott William Rooney, Nemes, Rooney, P.C., Farmington Hills, MI, for
      Petitioner.

Joseph Adam Lewis, U.S. Department of Justice, Washington, DC, for Respondent.

                  FINDINGS OF FACT AND RULING ON ENTITLEMENT1

        On January 22, 2019, Christine Heil filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that she suffered right arm and shoulder pain caused-
in-fact by the influenza (“flu”) vaccine she received on February 11, 2016. Petition at 1,
¶¶ 6, 32. Petitioner specifically asserts that she “has been in constant pain” since
vaccination (id. at ¶ 13) and that her “injuries have continued for more than six months

1 Because this unpublished Ruling contains a reasoned explanation for the action in this case, I am required
to post it on the United States Court of Federal Claims' website in accordance with the E-Government Act
of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling will be available to anyone with access to the internet. In accordance
with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I agree that
the identified material fits within this definition, I will redact such material from public access.

2National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all Section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).
after the vaccination injury on-set” (id. at 34). The case was assigned to the Special
Processing Unit of the Office of Special Masters.

       For the reasons set forth below, I find the onset of Petitioner’s right shoulder pain
occurred within 48 hours of vaccination, and she has satisfied the other requirements of
a Table shoulder injury related to vaccine administration (“SIRVA”). Furthermore, I find
Petitioner suffered the residual effects of the right arm and shoulder pain she experienced
post-vaccination for more than six months. Petitioner is entitled to compensation under
the Vaccine Act.

        I.      Relevant Procedural History

       Ms. Heil filed her Petition without medical records on the eve of the expiration of
the time to initiate a claim under the Vaccine Act’s statute of limitation.3 Over the
subsequent nine-month period, she filed an affidavit and some of the required medical
records. Exhibits 1-10, ECF Nos. 7, 11, 13, 19, 28, 30; Section 11(c).

       On December 12, 2019, Respondent indicated he was interested in engaging in
settlement discussions. ECF No. 35. Three months later, on March 16, 2020, he informed
me that the parties had reached an impasse. ECF No. 46. During this time, Petitioner filed
additional medical records and a second affidavit. Exhibits 11-14, ECF Nos. 40, 44.

       On April 30, 2020, Respondent filed his Rule 4(c) Report setting forth his objections
to compensation. ECF No. 48. Specifically, Respondent argued that Petitioner failed to
establish that the onset of her pain began within 48 hours of vaccination (as required for
a Table SIRVA claim), or that she suffered the residual effects of her injury for more than
six months. Id. at 6-7; see 42 C.F.R. § 100.3(a)(XIV)(B) and (c)(10)(ii) (Table entry for
SIRVA following receipt of a flu vaccine and Qualifications and Aids for Interpretation
(“QAI”) requirement regarding onset of pain); Section 11(c)(1)(D)(i) (regarding six-month
severity requirement).

       On July 8, 2020, I issued an order to show cause requiring Petitioner to file
additional evidence regarding onset and the duration of her injury. ECF No. 51. In
response, Petitioner filed a third affidavit (Exhibit 17); affidavits from her sister, her sister’s
husband, her husband, her two daughters, and her son-in-law (Exhibits 15-16, 18-21);
and medical records and letter of certification from her neurologist (Exhibits 22-23). ECF
Nos. 52, 54, 56, 58, 61, 65.

3 Alleging immediate pain upon vaccination on February 11, 2016, Petitioner was required to file her petition
prior to February 11, 2019. See Section 16(a)(2) (requiring that a petition be filed within 36 months of the
first symptom or manifestation of a petitioner’s injury).

                                                     2
       On July 27, 2021, Respondent filed a motion for a ruling on the record.
Respondent’s Brief in Support of his Motion for a Decision on the Record (“Motion”), ECF
No. 66. Arguing that Petitioner has still not provided sufficient evidence to establish onset
within 48 hours or to show that she has satisfied the Vaccine Act’s severity requirement,
Respondent requested that I dismiss Petitioner’s claim. Id. at 1, 8-14.

       Regarding the issue of onset, Respondent stresses the 55-day period before
Petitioner sought treatment of her right shoulder pain, and what he characterizes as
Petitioner’s vague language regarding the onset of her pain. Motion at 9-10. To support
his argument regarding severity, he emphasizes the improvement noted during
Petitioner’s last physical therapy (“PT”) session five months post-vaccination, the
fourteen-month gap in treatment thereafter, and his assertion that Petitioner received
another flu vaccine in her right deltoid nine months post-vaccination. Id. at 11, 13-14, He
cites multiple cases in which a similar gap in treatment caused the special master to find
a six-month duration of symptoms did not exist. Id. at 11-13.

        In response, Petitioner requests that I find her injury occurred within 48 hours and
lasted for more than six months, and “thereby allow[] this matter to go to hearing on
damages.” Petitioner’s Response to Motion (“Response”), filed Sept. 10, 2021, at 1, ECF
No. 69. Although not clearly stated, she appears to be requesting a ruling on entitlement
in her favor.

         Claiming that the almost two-month delay in treatment does not equate to a lack
of symptoms, Ms. Heil stresses that she has consistently reported an immediate onset of
her pain throughout provided medical histories and affidavits – an assertion which is
supported by the affidavits of her family members. Response at 7-8. Regarding the
duration of her injury, Petitioner claims that she had not fully recovered by her last PT
session in early July 2016, that she either did not mention her continued right shoulder
pain at subsequent appointments for other aliments because it would have been illogical
to do so or that she mentioned her pain and it was not noted in the record. She maintains
that she refused the second flu vaccine offered in November 2016. Id. at 8-10. Petitioner
distinguishes the primary case cited by Respondent, Lamarre, and cites Kirby for the
proposition that the failure to report every aliment a claimant is suffering when seeing a
medical provider does not mean the underlying ailment did not exist at the relevant time.
Id. (citing Lamarre v. Sec’y of Health & Human Servs., No. 17-0010V, 2019 WL 7556396
(Fed. Cl. Spec. Mstr. Nov. 6, 2019); Kirby v. Sec’y of Health & Human Servs., 997 F.3d
1378 (Fed. Cir. 2021)).

                                             3
       On October 1, 2021, Respondent filed a reply addressing the arguments made by
Petitioner in her response. Respondent’s Reply to Response (“Reply”), ECF No. 70. He
continues to stress Petitioner’s delay and gap in treatment, maintaining Petitioner has
provided not rationale for either. Id. at 1-2. He again asserts that “compensation is not
appropriate in this case, and the petition should be dismissed.” Id. at 3.

        Two weeks after Respondent filed his reply, Petitioner filed medical records which
included the results of an MRI performed on July 8, 2021. Exhibit 25, filed Oct. 14, 2021,
ECF No. 71; see Exhibit 25 at 2 (MRI results). On November 1, 2021, she filed the
complete medical records from the orthopedist who treated her right shoulder pain and
later left knee pain in 2016 (Exhibit 26), as well as medical records from her 2014 breast
implant surgery (Exhibit 27). ECF No. 73. She provided no reason why the complete
medical records from her orthopedist – now filed as Exhibit 26, which include the record
from an August 30, 2016 visit that appears sufficient to satisfy the Vaccine Act’s severity
requirement, was not previously provided, despite multiple requests from Respondent.4

        The matter is now ripe for adjudication.

        II.      Finding of Fact Regarding Onset and Duration

       At issue is whether Petitioner’s first symptom or manifestation of onset after
vaccine administration (specifically pain) occurred within 48 hours as set forth in the
Vaccine Injury Table and QAI for a Table SIRVA and whether her injury lasted more than
six-months as required for all Table and non-Table claims. See 42 C.F.R. § 100.3(a)
XIV.B.; 42 C.F.R. § 100.3(c)(10)(ii); Section 11(c)(1)(D)(i).

                 A.      Authority

      Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act
Section 11(c)(1). A special master must consider, but is not bound by, any diagnosis,
conclusion, judgment, test result, report, or summary concerning the nature, causation,
and aggravation of petitioner’s injury or illness that is contained in a medical record.
Section 13(b)(1). “Medical records, in general, warrant consideration as trustworthy

4  Initially, Petitioner filed a portion of these orthopedic records as part of the medical records from
Petitioner’s PCP. See Exhibit 3. Although Respondent requested medical records from orthopedic
treatment provided from April 26 through June 20, 2016, suspecting that some were outstanding, both in
his Rule 4(c) Report and Motion, Petitioner did not provide a complete copy of the orthopedic records until
this filing. See Rule 4(c) Report at 3 n.2; Motion at 3 n.3. When later filing these medical records, Petitioner
provided no explanation for their earlier omission or her denial, from as late as September 2021, that they
did not exist. Response at 5. A comparison of these medical records with the orthopedic records previously
filed in Exhibit 3 reveal not all had been provided until this most recent filing.

                                                       4
evidence. The records contain information supplied to or by health professionals to
facilitate diagnosis and treatment of medical conditions. With proper treatment hanging in
the balance, accuracy has an extra premium. These records are also generally
contemporaneous to the medical events.” Cucuras v. Sec’y of Health & Human Servs.,
993 F.2d 1525, 1528 (Fed. Cir. 1993).

      Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). “The medical
records made at the time treatment was sought or provided are far more reliable than the
witnesses' testimony, five years later, to the contrary.” Id. at *20.

       However, this rule does not always apply. The United States Court of Federal
Claims has recognized that “medical records may be incomplete or inaccurate.” Camery
v. Sec’y of Health & Human Servs., 42 Fed. Cl. 381, 391 (1998). “Written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Murphy v. Sec'y of Health & Human Servs., 23 Cl. Ct. 726, 733
(1991) (quoting with approval the standard used by the special master below), aff'd per
curiam, 968 F.2d 1226 (Fed. Cir. 1992). And the Federal Circuit recently “reject[ed] as
incorrect the presumption that medical records are accurate and complete as to all the
patient’s physical conditions.” Kirby v. Sec’y of Health & Human Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).

       The Claims Court has also said that medical records may be outweighed by
testimony that is given later in time that is “consistent, clear, cogent, and compelling.”
Camery, 42 Fed. Cl. at 391 (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-
2808, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). A special master
may find that the first symptom or manifestation of onset of an injury occurred “within the
time period described in the Vaccine Injury Table even though the occurrence of such
symptom or manifestation was not recorded or was incorrectly recorded as having
occurred outside such period.” Section 13(b)(2). “Such a finding may be made only upon
demonstration by a preponderance of the evidence that the onset [of the injury] . . . did in
fact occur within the time period described in the Vaccine Injury Table.” Id.

       The special master is obligated to fully consider and compare the medical records,
testimony, and all other relevant and reliable evidence contained in the record. La Londe,
110 Fed. Cl. at 204 (citing Section 12(d)(3); Vaccine Rule 8); see also Burns v. Sec’y of
Health & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within the
special master’s discretion to determine whether to afford greater weight to medical

                                             5
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).

              B.     Analysis

      I make the findings regarding onset and duration after a complete review of the
record to include all medical records, affidavits, and additional evidence. Specifically, I
base the findings on the following evidence:

          •   Prior to receiving the flu vaccine at issue, Petitioner suffered from obesity,
              breast cancer, hypothyroidism, depression, melanoma, and a right knee
              fracture due to a fall. Exhibit 3 at 17. She underwent a mastectomy in 2009,
              lap band surgery in 2011, right knee arthroscopy after a fall while
              rollerblading in 2012, and removal of her left breast implant due to infection
              in 2014. Id.; Exhibit 10 at 26 (regarding right knee surgery); Exhibit 27 at 16,
              50 (regarding implant surgery).

          •   On January 14, 2016, one month prior to receiving the vaccine alleged as
              causal, Petitioner was seen by the orthopedist who performed her 2012
              right knee arthroscopy for two months of right knee instability and a popping
              sensation with pain over her medial knee screw. Exhibit 10 at 26. Petitioner
              opted to undergo reconstructive knee surgery. Id. at 27-28.

          •   On February 11, 2016, Petitioner was seen by her primary care provider
              (“PCP”) for a refill of her medications. Exhibit 3 at 17-19. At this time, she
              received a flu vaccine intramuscularly in her right deltoid. Exhibit 7 at 2
              (vaccine record); see also Exhibit 3 at 20, 22 (noting 2/11/16 flu vaccine in
              record from the next PCP visit).

          •   On April 5, 2016 (almost two months post-vaccination), Petitioner returned
              to her PCP for a physical. Exhibit 3 at 20-23. At that visit, she complained
              of right arm pain which she attributed to the February 11, 2016 flu vaccine,
              reporting that her “right arm has been very painful since that injection.” Id.
              at 20. She shared her concern that the flu vaccine might have been injected
              into her bursa and indicated she had to quit working with her personal
              trainer “because she can’t do anything with her right arm.” Id. An
              examination revealed “[p]oint tenderness over [the] upper lateral arm . . .
              [and] pain lifting it anteriorly and horizontally above 45 degrees.” Id. at 21.
              Medical imaging of her right shoulder was ordered, and Petitioner was
              referred to orthopedics. Id. at 22.

                                              6
             •   Performed on April 12, 2016, the ultrasound revealed an intact rotator cuff,
                 evidence suggestive of fatty atrophy, and “[a] minimal amount of fluid in the
                 subacromial-subdeltoid bursa.” Exhibit 3 at 113. In the report, it was noted
                 that Petitioner had complained of “left[5] shoulder pain for approximately two
                 months.” Id. The same day, Petitioner also underwent a bilateral digital
                 mammogram which showed evidence consistent with her prior left breast
                 cancer and subsequent bilateral mastectomy. Id. at 114.

             •   On April 26, 2016, Petitioner was seen by an orthopedist for right shoulder
                 pain. Exhibit 26 at 10-11.6 Describing constant pain at a level of six to eight
                 out of ten which was exacerbated with use, Petitioner reported that “[s]he
                 had a flu shot several months ago and has had pain in the right upper arm
                 ever since.” Id. at 10. She identified the onset of her pain as February 11th.
                 Id. An examination revealed weakness and pain with the most painful being
                 resisted external rotation. Id. at 10-11. Diagnosing Petitioner with “an early
                 frozen shoulder,” the orthopedist administered a steroid injection and
                 prescribed PT. Id. at 11.

             •   On June 7, 2016, Petitioner returned to the orthopedist, indicating that the
                 cortisone injection “helped for about a week” and that “she ha[d] really been
                 pretty diligent with her exercises at home.” Exhibit 26 at 9. After discussing
                 the available options with Petitioner, the orthopedist determined that “the
                 best thing to do [wa]s to go ahead and manipulate her shoulder . . . [and]
                 put her in PT after that.” Id. He prescribed additional Tramadol.7 Exhibit 26
                 at 9.

             •   On June 20, 2016, Petitioner underwent a right shoulder manipulation under
                 general anesthesia and received a second cortisone injection. Exhibit 14 at
                 1. In the history found in this record, it is noted that Petitioner experienced
                 pain and stiffness within a few days of receiving the flu vaccine and “has

5 Although this one entry indicates the pain was in Petitioner’s left, rather than right, shoulder, it appears to
be incorrect – mostly likely due to a simple mistake. Other entries in the same record indicate the right
shoulder MRI was administered due to right shoulder pain. Exhibit 3 at 113. And it would be illogical for a
right shoulder MRI to have been ordered in response to left shoulder pain.

6All citations to this orthopedist’s medical records will be the complete copy provided in Exhibit 26. See
supra note 4.

7Tramadol hydrochloride is “an opioid analgesic used for the treatment of moderate to moderately severe
pain following surgical procedures and oral surgery, administered orally.” DORLAND’S ILLUSTRATED MEDICAL
DICTIONARY (“DORLAND’S “) at 1950 (32th ed. 2012).

                                                       7
    now gone on to develop a frozen shoulder with loss of motion in all planes.”
    Id. After the manipulation was performed, the cortisone injection was
    administered “through the anterior portal.” Id.

•   Following manipulation and the administration of a second injection,
    Petitioner attended five PT sessions in late June. Exhibit 4 at 17-21. At her
    first PT session on June 22, Petitioner rated her pain at a level of five out of
    ten. Id. at 9. It was again reported that “the pain in her shoulder started after
    a flu shot.” Id. The date of the manipulation is incorrectly listed as June 28.
    Id.

•   Petitioner attended one last PT session and was discharged on July 1,
    2016. Exhibit 4 at 2, 14. In the record from the July 1 PT session, it was
    noted that Petitioner’s pain was “better after every PT session.” Id. at 14.
    Under assessment, the box noting that the “Patient continues to make
    appropriate progress toward established functional treatment goals” was
    checked. Id. On the discharge sheet, it was reported that Petitioner had
    “made all functional goals” and was “100%”. Id. at 2. However, a mild
    restriction when lifting a gallon of milk was recorded, and Petitioner was
    instructed to continue a home exercise program (“HEP”). Id.

•   On July 5, 2016, Petitioner returned to her orthopedist for a follow-up
    appointment regarding her right shoulder manipulation. Exhibit 26 at 8.
    Noting that she was doing wonderfully, the orthopedist assessed her as
    having “great range of motion,” observing that her internal rotation “is to
    about L2 or so which is pretty good compared to where she started.” Id.
    Petitioner reported that her “pain ha[d] not completely subsided and
    requested another prescription for pain medicine.” Id. The orthopedist
    prescribed the requested medication and indicated “[w]e are going to put
    her back in physical therapy . . . and see how she does.” Id.

•   Petitioner returned to the orthopedist on August 23, 2016, complaining of
    “very significant pain in her left knee” which “came really just out of the blue.”
    Exhibit 26 at 6. The orthopedist noted that he “ha[d] taken care of . . .
    [Petitioner’s] shoulder in the past.” Id. He also characterized her left knee
    pain as “surprising” considering the earlier injury to her right knee and its
    arthritic and unstable condition. Id. Opining that Petitioner’s left knee pain
    may be due to a torn meniscus or bursitis, the orthopedist ordered an MRI
    bloodwork for her left knee and a brace for her right knee. Id. at 7.

                                    8
•   The MRI of Petitioner’s left knee, performed on August 29, 2016, showed a
    torn meniscus, effusion and a leaking Baker’s cyst, and evidence of an old
    injury. Exhibit 26 at 13.

•   On August 30, 2016, Petitioner attended a second follow-up appointment
    regarding her right shoulder manipulation. Exhibit 26 at 4. The record from
    that visits indicates “that her range of motion has improved significantly, she
    still has some pain from time to time and is still improving, but overall is
    happy with her progress.” Id. The orthopedist instructed Petitioner to
    continue her HEP and follow-up as needed. Explaining “that most frozen
    shoulder is resolved with conservative treatment,” he stated that “the fact
    that [Petitioner] is improving is a good sign for her prognosis.” Id. at 5.

•   On September 6, 2016, at a preoperative consult, the orthopedist discussed
    the results of Petitioner’s left knee MRI. Exhibit 26 at 3. The arthroscopic
    surgery to repair Petitioner’s left knee torn meniscus was performed on
    September 16, 2016. Id. at 18-20.

•   On November 18, 2016, Petitioner was seen by her PCP for a six-month
    follow-up and refill of her medication. Exhibit 3 at 24. The history in this
    record includes information about Petitioner’s “bad flu experience” when the
    shot was given “high up on [her] shoulder” as well as her subsequent “frozen
    shoulder release.” Id. Although the record contains some evidence
    indicating Petitioner was administered another flu vaccine that day, there is
    also a notation that she refused this vaccination. Id. at 25-26. There is
    nothing in this record indicating Petitioner was currently experiencing right
    shoulder pain.

•   It appears Petitioner did not seek treatment again until April 10, 2017, when
    she visited her PCP for a physical exam. Exhibit 3 at 27. At this visit, the
    only complaints listed are depression, anxiety, hypothyroidism, and
    hypertension. Petitioner reported more anxiety since stopping drinking.
    However, she admitted having one drink while on vacation in Hawaii. Id.
    The record contains no complaints or evidence of right shoulder pain or
    limited range of motion (“ROM”), even under the results of Petitioner’s
    physical examination. Id. at 27-30.

•   Petitioner returned to her PCP on April 24, 2017, complaining of a cough
    and chest congestion. Exhibit 3 at 31. Again, there is no evidence of right
    shoulder pain and limited ROM in this record. Id. at 31-32.

                                   9
•   On August 15, 2017, Petitioner was seen at the clinic of the orthopedist who
    performed her 2012 right knee arthroscopy - who she saw in January 2016
    for a re-evaluation of her right knee. Exhibit 10 at 7. She reported an
    exacerbation of her pain four days ago. Id. There is no mention of right
    shoulder pain or limited ROM in this record. Id. at 6-19.

•   On September 6, 2017, more than one year after the last entry containing
    an account of right shoulder pain, Petitioner was seen by a neurologist, for
    right shoulder pain following her flu vaccine a year and a half ago. Exhibit
    23 at 1. She noted that “[t]he pain is still there when she moves her right
    shoulder” and described it as sometimes radiating from her shoulder to her
    biceps and right wrist. Id. However, she reported that the pain is not
    constant or reproduced every time. And the results of the EMG performed
    that day were normal. Petitioner was told to follow-up with her PCP and
    orthopedist. Id. at 2-3.

•   Petitioner did not complain of her right shoulder pain again until almost one
    year later, on August 30, 2018, when seen by a treating physician who
    appears to be a new PCP. Exhibit 11 at 1. The chief complaint for this visit
    is listed as a follow-up appointment for hypertension. Id. However, no prior
    medical records for this provider have been filed, and Petitioner has not
    explained when and why she switched PCPs. In the record from this visit,
    it is noted that Petitioner “[a]lso continues to complain of right shoulder pain
    for the past 3 years.” Id. Her condition was described as “[p]ain radiating to
    right shoulder.” Id. The treating physician prescribed five days of
    Prednisone.

•   The medical records reveal that Petitioner has taken 300mg of Gabapentin
    since March 2015, when it was prescribed for her right knee pain. Exhibit 3
    at 14-15. It appears the dosage of this medication has remained throughout
    2015-17. Id. at 18, 21, 25, 28, 32; Exhibit 11 at 1, 3.

•   Petitioner filed three affidavits in this case: a basic affidavit, executed on
    January 21, 2019 (Exhibit 1); an affidavit regarding the effects of her injury
    on her work as a Mary Kay sales consultant, executed on January 29, 2020
    (Exhibit 13); and an affidavit regarding the November 18, 2016 appointment
    with Petitioner’s PCP, executed on August 15, 2020 (Exhibit 17). In the third
    affidavit, Petitioner maintained that she refused the flu vaccine offered at
    the November 18, 2016 PCP appointment. Exhibit 17 at ¶¶ 6, 8 (citing

                                   10
              Exhibit 3 at 25). She argues that the reason she rejected the vaccination
              was “continued pain in the right shoulder.” Id. at ¶ 10.

          •   Petitioner also provided supporting affidavits from six family members
              regarding the onset and duration of her pain. Exhibits 15-16, 18-21. The
              affidavit from her husband provides the most detail. Exhibit 18. Except for
              the initial information regarding their relationship to Ms. Heil, the other family
              member affidavits are virtually identical and provide only basic information.
              Exhibits 15-16, 19-21.

                     1.     Pain Onset

       It is common for a SIRVA petitioner to delay treatment, thinking his/her injury will
resolve on its own. The almost two-month delay in this case is thus not facially
unreasonable. Additionally, Petitioner did not seek treatment for any other medical
condition or illness during this 55-day period. Such intervening treatment evidence can in
many cases either corroborate a petitioner’s claim or undermine it – but it is totally absent
here.

       In multiple post-vaccination medical records, Petitioner consistently reported right
shoulder pain, which never ceased, since vaccination. Exhibit 3 at 20, 113; Exhibit 4 at 9;
Exhibit 26 at 10. Without fail, she attributed her injury to the flu vaccine she received on
February 11, 2016. Exhibit 3 at 20; Exhibit 4 at 9; Exhibit 26 at 10. On at least one
occasion, she identified the date of onset as February 11, 2016. Exhibit 26 at 10. While
these entries were based upon information provided by Petitioner, they still should be
afforded greater weight than more current representations, as they were uttered
contemporaneously with Petitioner’s injury for the purposes of obtaining medical care.

       The Federal Circuit has stated that “[m]edical records, in general, warrant
consideration as trustworthy evidence . . . [as they] contain information supplied to or by
health professionals to facilitate diagnosis and treatment of medical conditions.” Cucuras,
993 F.2d at 1528 (emphasis added). Thus, the Circuit has instructed that greater weight
should be accorded to this information even when the information is provided by
Petitioner.

       Although Respondent argues that Petitioner’s description of right shoulder pain
since vaccination is not specific enough to show an immediate onset, the record says
otherwise. Motion at 9. The use of the term “since” suggests that Petitioner’s right
shoulder pain occurred immediately – upon vaccination. And, on at least one occasion,
Petitioner identifies the date of vaccination as the onset of Petitioner’s pain as the date of

                                              11
vaccination. Exhibit 16 at 10; see also Exhibit 3 at 113 (April 12, 2016 entry describing
pain for two months).

       Only one history (in the medical record from Petitioner’s right shoulder
manipulation on June 20, 2016) indicates an onset more than a few days post-
vaccination. But this one later entry is outweighed by the numerous entries, closer in time
to vaccination, describing an immediate onset.

        Accordingly, I find there is preponderant evidence to establish the onset of
Petitioner’s pain occurred within 48 hours of vaccination. Specifically, I find the onset of
petitioner’s pain immediately upon vaccination.

                          2.      Duration of Pain and other Symptoms

       Petitioner obtained significant pain relief and improved ROM following her
manipulation, second cortisone injection, and PT in June 2016 - approximately four to five
months post-vaccination. However, later provided orthopedic records reveal Petitioner
continued to suffer a milder level of occasional pain as late as August 30, 2016 – more
than six months post-vaccination.

       On July 5, 2016 – four days after her last PT session, Petitioner reported that her
“pain had not completely subsided” and requested another prescription8 for pain
medication. Exhibit 26 at 8. Her ROM was characterized as great, and she was prescribed
60 Norco9 tablets. Exhibit 26 at 8. When she returned to the orthopedist on August 30,
2016, more than six months post-vaccination, Petitioner reported significant overall
improvement and only “some pain from time to time.” Id. at 4. Even though intermittent,
this pain is sufficient to satisfy the Vaccine Act’s severity requirement.

        Petitioner maintains that she continued to suffer residual effects of her SIRVA
injury for three years post-vaccination, but the record as it currently stands does not
adequately support the longer duration Petitioner claims. Following her report of
intermittent pain in late August 2016, despite seeking treatment for other conditions on
numerous occasions, Petitioner complained of right shoulder pain on only two occasions:
during a September 2017 visit to the neurologist and August 2018 visit to a treating
physician who appears to be her new PCP. In September 2017, Petitioner admitted that

8   On June 7, 2016, Petitioner had been prescribed 60 Tramadol tablets. Exhibit 26 at 9; see supra note 7.
9Norco is a “trademark for combination preparations of hydrocodone bitartrate and acetaminophen.”
DORLAND’S at 1290.

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her pain occurred only occasionally with movement. For the first time in September 2017,
she described right shoulder pain radiating to her wrist.

       In their affidavits, Petitioner’s family members provided extremely general and
nearly identical statements merely indicating Petitioner complained of pain after her last
PT session on July 1, 2016. Exhibit 15-16, 18-21. No further information regarding the
timing of these statements was provided. Thus, they provide nothing to contradict or
supplement the information already contained in the medical records in this case.

        As it currently stands, the record shows that Petitioner was suffering mild SIRVA
symptoms as late as August 30, 2016. However, it appears her injury had almost resolved
by that time. And Petitioner did not seek treatment again or complain of any symptoms
until almost a year later. Currently the record does not contain sufficient evidence to
connect Petitioner’s two subsequent complaints of pain (in late 2017 and 2018) to the
SIRVA injury she appears to have suffered in February 2016. This will bear on my
damages calculation, but it does not prevent Petitioner from obtaining an entitlement
award.

       III.   Requirements for Table SIRVA

       Because I have determined the onset of her right shoulder pain occurred
immediately upon vaccination, Petitioner has met the timing required for a Table SIRVA
and has fulfilled the second of the four QAI Table criteria. See 42 C.F.R. § 100.3(a)(XIV)
(Table entry for SIRVA following influenza vaccine); 42 C.F.R. § 100.3(c)(10)(ii) (second
QAI requirement). To establish that she suffered a Table SIRVA, Petitioner must satisfy
the additional three QAI requirements. 42 C.F.R. § 100.3(c)(10)(i) (iii-iv).

       The record in this case contains no indication that Petitioner suffered prior right
shoulder issues. See 42 C.F.R. § 100.3(c)(10)(i). Nor is there evidence of any other
condition or abnormality that would explain the left shoulder pain she experienced in
2016. See 42 C.F.R. § 100.3(c)(10)(iv).

        Petitioner consistently described the pain she experienced in 2016 as located in
her right upper arm or shoulder. Exhibit 3 at 20; Exhibit 4 at 9; Exhibit 14 at 1; Exhibit 26
at 8, 10. She did not describe pain which radiated to other locations until 2017. Exhibit 23
at 1. Likewise, Petitioner exhibited limited ROM in only her right shoulder. Thus, Petitioner
has satisfied all QAI criteria for a Table SIRVA.

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       IV.    Additional Requirements for Entitlement

        Because Petitioner has satisfied the requirements of a Table SIRVA, she need not
prove causation. Section 11(c)(1)(C). However, she must satisfy the other requirements
of Section 11(c) regarding the vaccination received, the duration and severity of
petitioner’s injury, and the lack of other award or settlement. Section 11(c)(A), (B), and
(D).

        The vaccine record shows Petitioner received the flu vaccine in her right deltoid at
her PCP in Flint, Michigan. Exhibit 3 at 20; Exhibit 7 at 2; see Section 11(c)(1)(A)
(requiring receipt of a covered vaccine); Section 11(c)(1)(B)(i) (requiring administration
within the United States or its territories). Additionally, there is no evidence that Petitioner
has collected a civil award for his injury. See Section 11(c)(1)(E) (lack of prior civil award).

       Finally, as I have determined in this ruling, the medical records show that Petitioner
continued to suffer right shoulder pain at least as late as August 30, 2016. See supra
Section II.B.2. Thus, Petitioner suffered the residual effects of her SIRVA for at least six
months post-vaccination, in this case beyond August 11, 2016. See Section 11(c)(1)(D)(i)
(statutory six-month requirement). Thus, Petitioner has satisfied all requirements for
entitlement under the Vaccine Act.

       V.     Conclusion

       Based on the entire record in this case, I find that Petitioner has provided
preponderant evidence satisfying all requirements for a Table SIRVA and the
Vaccine Act’s severity requirement needed for both Table and non-Table claims.
Petitioner is entitled to compensation in this case.

IT IS SO ORDERED.

                                    s/Brian H. Corcoran
                                    Brian H. Corcoran
                                    Chief Special Master

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