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Background: Claims of shoulder injury now account for half of all claims to the Vaccine Injury Compensation Program. Reports from databases of claims or potential adverse events note a relatively high mean age and high prevalences of rotator cuff tendinopathy and adhesive capsulitis-common shoulder problems that might be incidental to vaccination. Published case reports provide much more detail about individual patients than is available in databases. A review of published cases provides an opportunity for more detailed review of symptoms, diagnoses, pathology, treatment, and prognosis. Such a review can better assess the relative likelihood that pathologies associated with new persistent shoulder symptoms after vaccination are coincidental or unique to and caused by vaccine.Questions/purposes: Regarding published case reports addressing persistent shoulder pain after vaccination: (1) In what proportion of patients was a specific diagnosis made? (2) What diagnoses were most common? (3) Among patients treated nonsurgically, what proportion resolved, and over what time span did they resolve?Methods: In August 2020, we searched PubMed and Embase between 2006 and 2020 using the following search strategy: Search 1: (shoulder dysfunction OR shoulder pain OR shoulder bursitis OR rotator cuff tendonitis OR adhesive capsulitis OR glenohumeral arthritis AND [vaccine OR vaccination OR immunization]); Search 2: (shoulder injury related to vaccine administration or SIRVA). The search was supplemented by reviewing reference lists of identified studies. Inclusion criteria were any detailed report of three or fewer cases involving shoulder pain after vaccine administration. Twenty published reports of 29 patients were identified and assessed by two reviewers independently. One reported glenohumeral joint infection was excluded because the relationship between this type of relatively uncommon, discrete diagnosis and vaccination raises different considerations. We assumed a high risk of bias, although we are not aware of bias assessment tool for case reports. We recorded and summarized patient demographics, symptoms, examination and imaging findings, surgery findings, diagnoses, treatments, and outcomes. Seventy-five percent (21 of 28) of patients were women, with a mean age of 54 ± 19 years. In search of an underlying pathology, at least one diagnostic study was performed in 82% (23 of 28) of patients including radiographs in seven, ultrasound in seven, and MRI in 16 patients (some patients underwent more than one type of imaging). We distinguished specific pathophysiological diagnosis from shoulder pain and stiffness, counted the most common diagnoses among patients a specific diagnosis, and tracked symptom resolution among patients treated nonoperatively.Results: A specific diagnosis was made in 57% (16 of 28) of patients. Twelve patients had pain and limitation of motion due to pain but no specific pathological diagnosis. The most common specific diagnoses were rotator cuff tendinopathy (9 of 16) and adhesive capsulitis (4 of 16). Less common specific diagnoses included rotator cuff arthropathy (and rheumatoid arthritis) and suspected septic arthritis with nonspecific synovitis on arthroscopy. One patient had transient MRI signal change in the humeral head, which was interpreted as osteonecrosis that resolved in a manner not typical for that diagnosis. Of the 17 patients treated nonsurgically, 15 reported resolution, and two had incomplete symptom resolution with the mean 6-month evaluation period.Conclusion: The observation that persistent shoulder pain after vaccination overlaps with common shoulder pathology-both in large databases as well as in more detailed reports of specific patients as analyzed in this review-establishes a high probability of a coincidental rather than a causal association. In the absence of high-quality experimental evidence of vaccine-specific shoulder pathology, in our opinion, it seems safest and healthiest to assume that perceived shoulder injury related to vaccine administration (SIRVA) is due to misinterpretation of new symptoms from established pathology rather than a new, vaccine-specific pathology.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Shoulder injury related to vaccine administration (SIRVA) is postulated to be an immune-mediated inflammatory response to a vaccine antigen injected into or near the subacromial bursae or synovium, leading to shoulder pain and dysfunction. The number of studies on this topic is rapidly increasing. Recent comparative studies have reported conflicting conclusions, which suggests that a systematic review of the best-available evidence may be helpful.Questions/purposes: In this systematic review, we asked: What are the (1) clinical characteristics, (2) diagnoses, and (3) management approaches and outcomes reported in association with SIRVA?Methods: A search was performed on October 4, 2021, of the PubMed and Medline databases for studies related to SIRVA. Inclusion criteria were English-language comparative studies, case series, and case reports that involved shoulder pain occurring after vaccination. Studies of exclusively neurologic conditions after vaccination were excluded. Forty-two studies met the eligibility criteria, including three retrospective comparative studies (72 patients and 105 controls), five database case series (2273 patients), and 34 case reports (49 patients). Study quality was assessed for the database case series and retrospective comparative studies using the Methodological Index for Non-randomized Studies tool.Results: Among patients in the case reports, the median age was 51 years (range 15-90 years), and 73% (36 of 49) were women. BMI was reported for 24% of patients (12 of 49) in case reports, with a median of 23.5 kg/m2 (range 21-37.2 kg/m2). The most common symptoms were shoulder pain and reduced ROM. The most common diagnoses were shoulder bursitis, adhesive capsulitis, and rotator cuff tears. The most frequent management modalities included physical or occupational therapy, NSAIDs, and steroid injections, followed by surgery, which was generally used for patients whose symptoms persisted despite nonsurgical management. Full resolution of symptoms was reported in 2.9% to 56% of patients.Conclusion: The association between inflammatory conditions of the shoulder (such as bursitis) and vaccination appears to be exceedingly rare, occurring after approximately 1:130,000 vaccination events according to the best-available comparative study. Currently, there is no confirmatory experimental evidence supporting the theory of an immune-mediated inflammatory response to vaccine antigens. Although the clinical evidence is limited, similar to any bursitis, typical treatments appear effective, and surgery should rarely be performed. Additional research is needed to determine the best injection technique or evaluate alternate injection sites such as the anterolateral thigh that do not involve positioning a needle close to the shoulder. [ABSTRACT FROM AUTHOR]

Chen et al. [[3]] showed intraarticular injections had improved outcome for pain relief compared to subacromial injection but no difference in function. Treatment management for Stage 1 often consists of NSAIDs, supervised physical therapy, and intraarticular corticosteroid injections, though several studies recommend early intervention with intra-articular corticosteroid injections in the early inflammatory or frozen stages of adhesive capsulitis [[2], [10]], and this may be more efficacious than other approaches [[10], [14], [16]]. Finally, a randomized control trial that used three different locations (rotator interval, intraarticular, and subacromial) showed that injections in the rotator interval yielded the best results followed by intraarticular injections for pain and passive ROM. CORR Insights®: Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder?. [Extracted from the article]

Background: Olecranon bursitis might be a minor problem in the outpatient clinic but relatively be common to occur. However, there are few well-designed studies comparing approaches to treatment.Questions/purposes: (1) Which treatment (compression bandaging with nonsteroidal antiinflammatory drugs [NSAIDs], aspiration, or aspiration with steroid injections) is associated with the highest likelihood of resolution of nonseptic olecranon bursitis? (2) Which treatment is associated with earliest resolution of symptoms? (3) What factors are associated with treatment failure by 4 weeks?Methods: We enrolled 133 patients from two centers; after applying prespecified exclusions (septic bursitis or concomitant inflammatory arthritis, intraarticular elbow pathology, recent aspiration or steroid injection done elsewhere, and refusal to participate), 90 patients were randomly allocated to receive compression bandaging with NSAIDs (C), aspiration (A), or aspiration with steroid injection (AS) groups (30 patients in each). The groups were similar at baseline in terms of age and gender. Seven patients (four from Group A and three from Group AS) were lost to followup. All patients were followed up weekly for 4 weeks, and the same treatment procedure was repeated if the bursitis recurred with any substantial fluid collection. At 4 weeks, the state of resolution and pain visual analog scale (VAS) were evaluated. Failed resolution was defined as presence of persistent olecranon bursal fluid collection at Week 4 after the initiation of the treatment; on the contrary, if bursal fluid collection was clinically reduced or completely disappeared by the end of Week 4, the treatment was considered successful. We compared the proportion of resolution by Week 4 and the median times to resolution among the treatment groups. In addition, we evaluated whether the resolution affected pain VAS and what factors were associated with the resolution.Results: There were no differences in the proportion of patients whose bursitis resolved by Week 4 among the three treatment groups (Group C: 25 of 30 [83%], relative risk of resolution failure: 0.68 [95% confidence interval {CI}, 0.27-1.72], p = 0.580; Group A: 17 of 26 [65%], relative risk of resolution failure: 2.19 [95% CI, 0.98-4.87], p = 0.083; Group AS: 23 of 27 [85%], relative risk of resolution failure: 0.59 [95% CI, 0.22-1.63], p = 0.398) (p = 0.073). Steroid injection after aspiration (Group AS) was associated with the earliest resolution (2.3 weeks [range, 1-4 weeks]) when compared with aspiration alone (Group A; 3.1 weeks [range, 2-4 weeks]) and compression bandaging with NSAIDs (Group C; 3.2 weeks [range, 2-4 weeks]), p = 0.015). Longer duration of symptoms before treatment was the only factor associated with treatment failure by 4 weeks (failed resolution: 6 weeks [range, 2-9 weeks]; successful resolution: 4 weeks [range, 0.4-6 weeks]; p = 0.008).Conclusions: With the numbers available, there were no differences in efficacy when compression bandaging with NSAIDs, aspiration, and aspiration with steroid injection were compared. However, we were powered only to detect a 30% difference, meaning that if there were a smaller difference in efficacy among the groups, we might not have detected it in a study of this size. Our data can be used as pilot data to power future prospective (and likely multicenter) trials. Because olecranon bursitis can recur, and because treatments like aspiration and aspiration with steroid injection can cause complications, unless future trials demonstrate clear efficacy advantages of aspiration and/or injection both at short and longer terms, we suggest that compression bandaging and a short course of NSAIDs may offer the most appropriate balance of safety and efficacy.Level Of Evidence: Level II, therapeutic study. [ABSTRACT FROM AUTHOR]

The author presents a commentary on the article A Randomized Trial Among Compression Plus Nonsteroidal Antiinflammatory Drugs, Aspiration, and Aspiration With Steroid Injection for Nonseptic Olecranon Bursitis by Kim and colleagues. Topics include need for knowing the disability associated with olecranon bursitis using joint-specific outcome tools, and address the population based natural history of olecranon bursitis, the longitudinal experience of the disease, and its treatments.