I got a pneumonia shot - and then the pain began...
Our vulnerable shoulders
Shoulder injuries become more likely as we age. The shoulder is one of the most complex and unstable joints in the body, making it especially vulnerable to wear and tear, and to injury. “Shoulder problems are incredibly common,’’ says Christopher Annunziata, head orthopedic physician for the Washington Redskins, whom I went to see after the pain did not go away. “They are right up there with the aging knee and aching lower back.’’
In 2012, more than 9.6 million Americans sought help from their physicians for shoulder problems, according to the American Academy of Orthopaedic Surgeons. Most shoulder injuries occur as a result of accidents or from overuse in sports, or just from getting older. They can also happen during everyday activities.
Shoulder injuries from vaccinations are rare, according to public health officials. Nevertheless, the problem has received growing attention in recent years as more immunizations are done outside doctors’ offices, especially during flu season through vaccination clinics offered at workplaces, pharmacies and grocery stores.
In public settings, “some people go in . . . and lower their collar, exposing only the top of the deltoid,” says Marko Bodor, a California orthopedist who authored a 2006 report that described vaccination-related shoulder injuries in two of his patients. “They are more likely to get their shot in the top of the deltoid because they can’t pull their shirt all the way down.’’
In 2011, the Institute of Medicine issued a report on the adverse effects of vaccines, concluding, among other things, that vaccine administration can lead to shoulder problems and stating that it found “convincing evidence of a causal relationship between injection of vaccine . . . and deltoid bursitis, or frozen shoulder, characterized by shoulder pain and loss of motion.”
My inoculation took place in a physician’s office, administered by a nurse. I now believe she inadvertently went too high up because I was sitting in a chair — talking to someone else in the office — and she was standing. (See sidebar.)
After eight days of pain, I called the practice. One of the doctors suggested I take ibuprofen for a few days. I don’t like taking drugs unless unavoidable — and in this case I felt it would only be masking the pain — so I ignored the advice.
Damage can be chronic
Inactivated vaccines, which are made from killed virus, contain adjuvants, or additional chemicals, that help promote a robust immune response. Injections are given to adults in the middle of the deltoid, the meatiest part of the muscle, which provides lots of space to both maximize the immune response and minimize adverse reactions.
“A vaccine is an immunologically sensitive substance, and if you were to receive an injection too high — in the wrong place — you could get pain, swelling and reduced range of motion in that area,’’ says Tom Shimabukuro, deputy director of the Centers for Disease Control and Prevention’s immunization safety office. When that happens, he adds, “an acute process can become chronic.”
A 2010 study that examined 13 cases of post-vaccination shoulder injuries found nearly half of the patients reported that the vaccine was injected “too high” into the arm, suggesting “that in some of our cases, the injury may have been the result of improper injection technique,” the study said. Moreover, their shoulders began to hurt either immediately or within 24 hours, causing pain and limited range of motion. MRI scans showed, among other things, bursitis and rotator cuff tears in several of the patients.
A third of the patients needed surgery, some of them twice.
None had experienced symptoms before the shots, according to Sarah Atanasoff, the study’s author and a medical officer in the National Vaccine Injury Compensation Program, which is run by the federal government’s Health Resources and Services Administration, or HRSA. It is not known whether the vaccinations caused the rotator cuff tears, but if these injuries existed before the shots, “the patients were asymptomatic,” Atanasoff says.
“As soon I got the shot, it hurt so bad, I jumped,’’ says Debby Russo, 60, of Eagleville, Pa., who got a flu shot in 2011 at a pharmacy. An MRI showed excessive fluid buildup in the bursa. “By the time I got home, I couldn’t lift my arm out to the side.’’
Between 2011 and 2014, the compensation program received 136 claims alleging upper-extremity injuries, including SIRVA (along with others such as general arm pain and disfiguring lumps). As of May, the federal court that adjudicates such claims had awarded compensation for 102 of them, with payments totaling about $16 million.
In July, HRSA proposed adding SIRVA to the program’s list of covered injuries. While SIRVA has not been on the list until now, the court has awarded compensation for such injuries based on growing evidence of causation.
The Vaccine Adverse Event Reporting System (VAERS), run jointly by the CDC and the Food and Drug Administration, has received about 1,200 complaints of post-vaccination shoulder-related injuries since 1990, according to the CDC. Shimabukuro stresses, however, that a report does not necessarily mean the vaccine caused the injury, only that it occurred sometime after a vaccination.
“Vaccines have a utility, and people should get them, but it’s important that people also realize there can be injuries,’’ says Paul Brazil, a Philadelphia attorney who represents about 150 clients with vaccine-related shoulder injuries. “Most are flu-shot cases because these shots are so common. Nobody believes people who say they’ve been hurt by flu shots, but it can happen.’’
There is no single way to treat shoulder injuries, regardless of how they occur. Treatments that work for some may not work for others.
Physical therapy after an injury can help keep the shoulder flexible and strengthens the muscles that control the shoulder blade. Cortisone injections suppress the immune response, thus relieving pain and inflammation. Bodor uses ultrasound imaging to target precise sites for cortisone injections, which cured Cassayre after several months of ineffective physical therapy.
I had an MRI in May. The images showed excessive fluid buildup and inflammation in the bursa, and a small incomplete tear in my rotator cuff. The tear is in line with the fibers of my cuff, much like a split in a seam. It’s unclear whether I had the tear before the shot or whether the shot caused it. I’d had no prior symptoms, and Annunziata says the shot might either have caused the tear — if the needle went into the cuff — or stirred up a prolonged inflammatory response in the area, causing the tear to become painful.
I’ve had two cortisone injections and several months of physical therapy. Relief has been temporary. Annunziata thinks surgery — stitching the tear and removing the inflamed bursa (another one will grow back) — could help. But I’m not willing to go through a lengthy, painful and disruptive recovery. Also, I don’t want to quit my workouts, driving or walking my dogs for the months it would take for the initial phase of recuperation.
I can lift my arm, but it hurts. It’s okay when I go running, but it bothers me when I swim. I’ve curtailed weightlifting. It hurts to put my arm through a sleeve or to pull a T-shirt over my head. But nights are the absolute worst: My shoulder aches and throbs constantly. I have not an uninterrupted, pain-free night’s sleep in nearly a year. This is minor compared with health challenges that other people face. Still, it didn’t have to happen.
Having rejected surgery, I’ve decided to try something else, safe but still regarded in some circles as experimental.
A chance worth taking
I recently went to see John Ferrell, who practices regenerative orthopedics in the Washington area, to find out whether I might benefit from a therapy that uses the body’s own blood platelets to heal injuries. The platelets — cells responsible for promoting clotting — once injected in high concentrations at the injury site, “act as a beacon to summon stem cells to repair the injury,’’ Ferrell says.
Studies are underway to evaluate the effectiveness of this approach; this research may eliminate one of the reasons it is not covered by insurance. (The American Academy of Orthopaedic Surgeons says that the treatment “holds great promise” for orthopedic injuries and that “the risks associated with it are minimal.’’) Ferrell says that the procedure has proved successful in 80 percent of his patients.
I decided to try it and had the injection on Friday. It will take weeks before I know whether it has worked.
Now recovered after her surgery, Russo says: “Who would have thought that a routine shot would cause so much misery and pain? It scares me to get shots now.’’
Vaccines have an impressive safety record. No one should shun them because of the small risk of shoulder injury. The consequences of getting a vaccine-preventable disease can be far more serious.
Flu season is here, and recently I got the shot.
I went to my doctor’s office and — because I believe what happened last December was an unfortunate accident — I let the same nurse deliver it. It went fine.
I got it in the other arm, and I did not take my eyes off the needle. It went into the right place and didn’t hurt a bit. The soreness was gone in 24 hours.
Cimons writes frequently for The Post on health, science and environmental issues.
How to give — and receive — a safe shot:
• An intramuscular vaccination in the arm should avoid the top third of the deltoid muscle and aim for the middle of the muscle, its thickest portion.
• Both the patient and the provider should be on the same plane — that is, either both sitting or both standing, although sitting is preferred. This reduces the risk of inadvertently injecting the vaccine too high up into the shoulder. (When I received the injection that led to problems, I was sitting down and the nurse was standing up). It is also a good idea to hold the arm out a little from the side, a position that helps protect the bursa.
• The injection should go into the muscle at a 90-degree angle to the skin.
• The Centers for Disease Control and Prevention provides specific recommendations for needle size based on the patient’s weight, but generally “the needles get bigger as the patient gets bigger,’’ says JoEllen Wolicki, a nurse educator in CDC’s immunization services division.
For patients and practitioners, the CDC’s Web site has illustrations and recommendations describing proper vaccine protocols. Go to www.cdc.gov/pubs/pinkbook/vac-admin and scroll down to the photos and drawings.