What is the likely diagnosis, evaluation, and management for a patient who develops new shoulder pain with limited range of motion a few days to weeks after receiving an intramuscular deltoid vaccine?

SIRVA (Shoulder Injury Related to Vaccine Administration)

Diagnosis

SIRVA is a distinct clinical entity characterized by shoulder pain and limited range of motion developing within 48 hours of intramuscular deltoid vaccine administration in patients with no prior shoulder pathology. 1, 2

Key Diagnostic Features to Identify:

• Temporal relationship: Symptom onset within 48 hours (up to 2-4 days) after deltoid injection 1, 2
• Pain location: Anterior or anterolateral shoulder pain that worsens with overhead activities 3
• Range of motion: Marked restriction in active shoulder movements, particularly abduction with external/internal rotation 3, 2
• Severity spectrum: Ranges from mild restriction to complete loss of motion (0° flexion, no rotation possible) 2
• Duration: Symptoms persist beyond one week, distinguishing SIRVA from transient post-injection soreness 1, 4

Physical Examination Priorities:

• Document specific range of motion limitations in external rotation, abduction, and internal rotation 5
• Assess for focal tenderness over biceps tendon, supraspinatus, and subacromial region 5
• Evaluate scapular position and identify any dyskinesis or winging 5
• Test muscle tone throughout shoulder girdle to assess for spasticity 5

Diagnostic Imaging:

• MRI findings (obtain within first week if severe): Glenohumeral joint effusion and synovitis, subacromial-subdeltoid bursitis, fluid in subscapularis recess, possible infraspinatus tendinitis with bone marrow edema 2, 4
• Ultrasound can detect rotator cuff abnormalities with 85% sensitivity and 90% specificity 3, 5
• Radiographs should be obtained initially to exclude fracture or other bony pathology 6

Management Algorithm

Phase 1: Immediate Treatment (0-2 weeks)

For patients presenting within days of symptom onset with acute severe restriction, early corticosteroid injection provides the most rapid symptom resolution and should be strongly considered as first-line treatment. 7

• Subacromial corticosteroid injection: Two case reports demonstrated complete symptom resolution within 1 month when CSI administered within 5 days of onset, compared to 65% of untreated patients having pain >1 month and 25% having pain >3 months 7
• NSAIDs: Acetaminophen or ibuprofen for pain relief 3, 5, 2
• Rest in sling: For severe cases with complete motion restriction, use for one week 2
• Avoid aggressive passive range-of-motion exercises: Can worsen shoulder pathology 6, 5

Phase 2: Conservative Treatment (2-6 weeks)

• Gentle stretching and mobilization: Focus specifically on increasing external rotation and abduction 3, 5
• Gradual active range of motion: Increase movement progressively while restoring shoulder girdle alignment 3, 5
• Patient education: Instruct on correct positioning and handling of the affected arm 5
• If subacromial-subdeltoid bursitis confirmed on MRI: Subacromial steroid injection provides good pain relief 2

Phase 3: Intermediate Treatment (6-12 weeks)

• Rotator cuff strengthening: Target supraspinatus, infraspinatus, subscapularis, and teres minor 5
• Scapular stabilizer exercises: Emphasize posterior shoulder musculature to counterbalance anterior muscles 5
• Address scapular dyskinesis: Correct any winging or abnormal movement patterns through specific exercises 5

Phase 4: Advanced Treatment (12+ weeks if needed)

• Functional activity progression: Return to work-specific or daily activities with proper mechanics 5
• Ensure complete symptom resolution before advancing to full unrestricted activity 5

Critical Management Pitfalls to Avoid

• Do not delay corticosteroid injection in acute severe cases—early intervention (within 5 days) dramatically improves outcomes compared to conservative management alone 7
• Do not perform overhead pulley exercises: These worsen shoulder pathology 8
• Do not overlook scapular dyskinesis: Assessment and treatment of scapular mechanics is essential for resolution 5
• Do not ignore concurrent conditions: Screen for adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment 5

When to Escalate Care

• Refer for orthopedic evaluation if symptoms persist or recur after completing 12 weeks of structured physical therapy 5
• Consider surgical intervention for recalcitrant cases or if infection suspected 1
• Suprascapular nerve block may be considered as adjunctive treatment, showing superiority to placebo for up to 12 weeks 5

Prevention Considerations

SIRVA is a preventable iatrogenic condition caused by improper injection technique—the needle should be placed in the deltoid muscle belly, not too high (avoiding subacromial bursa) or too deep (avoiding glenohumeral joint). 9, 1, 4