# Cavanaugh v. Secretary of Health and Human Services

> United States Court of Federal Claims · December 15, 2025

URL: https://www.frixlaw.com/law-library/cases/11224919

## Case

- **Court:** United States Court of Federal Claims
- **Decided:** December 15, 2025
- **Precedential status:** Unpublished
- **Opinion:** Opinion
- **Judges:** Daniel T. Horner
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/11224919

## How later opinions describe it (automated extraction)

- holding that it is within the special master's discretion to determine whether to afford greater weight to contemporaneous medical records than to other evidence
- holding that “[t]he special master concluded that the expert based his opinion on facts not substantiated by the record. As a result, the special master properly rejected the testimony of petitioner's medical expert.”
- holding that the special master was correct in noting that “[w]hen an expert assumes facts that are not supported by a preponderance of the evidence, a finder of fact may properly reject the expert’s opinion” (alteration in original

## Opinion text

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 21-567V
Filed: November 20, 2025

Special Master Horner
JULIE CAVANAUGH,

Petitioner,
v.

SECRETARY OF HEALTH AND
HUMAN SERVICES,

Respondent.

Zachary James Hermsen, Whitfield & Eddy Law, Des Moines, IA, for petitioner.
Ryan Nelson, U.S. Department of Justice, Washington, DC, for respondent.

DECISION1

On January 11, 2021, petitioner filed a petition under the National Childhood
Vaccine Injury Act (“Vaccine Act”), 42 U.S.C. § 300aa-10, et seq. (2012),2 alleging that
she suffered a Table Injury of a shoulder injury related to vaccine administration
(“SIRVA”) affecting her right shoulder and following an influenza (“flu”) vaccination she
received on January 14, 2020. (ECF No. 1.) For the reasons set forth below, I
conclude that petitioner is not entitled to compensation.
I. Applicable Statutory Scheme

Under the National Vaccine Injury Compensation Program, compensation
awards are made to individuals who have suffered injuries after receiving vaccines. In

1
Because this document contains a reasoned explanation for the action taken in this case, it must be
made publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic
Government Services). This means the document 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.
2
Within this decision, all citations to § 300aa will be the relevant sections of the Vaccine Act at 42 U.S.C.
§ 300aa-10, et seq.

1
general, to gain an award, a petitioner must make a number of factual demonstrations,
including showing that an individual received a vaccination covered by the statute;
received it in the United States; suffered a serious, long-standing injury; and has
received no previous award or settlement on account of the injury. Finally – and the key
question in most cases under the Program – the petitioner must also establish a causal
link between the vaccination and the injury.
In some cases, the petitioner may simply demonstrate the occurrence of what
has been called a “Table Injury.” That is, it may be shown that the vaccine recipient
suffered an injury of the type enumerated in the “Vaccine Injury Table,” corresponding to
the vaccination in question, within an applicable time period following the vaccination
also specified in the Table. If so, the Table Injury is presumed to have been caused by
the vaccination, and the petitioner is automatically entitled to compensation, unless it is
affirmatively shown that the injury was caused by some factor other than the
vaccination. § 300aa-13(a)(1)(A); § 300 aa-11(c)(1)(C)(i); § 300aa-14(a); § 300aa-
13(a)(1)(B).
As relevant here, the Vaccine Injury Table lists SIRVA as a compensable injury if
it occurs within 48 hours of vaccine administration. § 300aa-14(a), amended by 42
C.F.R. § 100.3. Table Injury cases are guided by statutory “Qualifications and aids in
interpretation” (“QAI”), which provide more detailed explanation of what should be
considered when determining whether a petitioner has suffered an injury listed on the
Vaccine Injury Table. 42 C.F.R. § 100.3(c). To be considered a “Table SIRVA,” a
petitioner must show that his/her injury fits within the following definition:
SIRVA manifests as shoulder pain and limited range of motion occurring
after the administration of a vaccine intended for intramuscular
administration in the upper arm. These symptoms are thought to occur as
a result of unintended injection of vaccine antigen or trauma from the needle
into and around the underlying bursa of the shoulder resulting in an
inflammatory reaction. SIRVA is caused by an injury to the musculoskeletal
structures of the shoulder (e.g. tendons, ligaments, bursae, etc.). SIRVA is
not a neurological injury and abnormalities on neurological examination or
nerve conduction studies (NCS) and/or electromyographic (EMG) studies
would not support SIRVA as a diagnosis . . . A vaccine recipient shall be
considered to have suffered SIRVA if such recipient manifests all of the
following:

(i) No history of pain, inflammation or dysfunction of the affected
shoulder prior to intramuscular vaccine administration that would
explain the alleged signs, symptoms, examination findings, and/or
diagnostic studies occurring after vaccine injection;

(ii) Pain occurs within the specified time-frame;

(iii) Pain and reduced range of motion are limited to the shoulder in which
the intramuscular vaccine was administered; and

2
(iv) No other condition or abnormality is present that would explain the
patient’s symptoms (e.g. NCS/EMG or clinical evidence of
radiculopathy, brachial neuritis, mononeuropathies, and any other
neuropathy).

42 CFR § 100.3(c)(10).

Alternatively, if no injury falling within the Table can be shown, the petitioner may
still demonstrate entitlement to an award by showing that the vaccine recipient’s injury
was caused-in-fact by the vaccination in question. § 300aa-13(a)(1)(A); § 300aa-
11(c)(1)(C)(ii). To so demonstrate, a petitioner must show that the vaccine was “not
only [the] but-for cause of the injury but also a substantial factor in bringing about the
injury.” Moberly v. Sec'y of Health & Human Servs., 592 F.3d 1315, 1321-22 (Fed. Cir.
2010) (quoting Shyface v. Sec'y of Health & Human Servs., 165 F.3d 1344, 1352–53
(Fed. Cir. 1999)); Pafford v. Sec'y of Health & Human Servs., 451 F.3d 1352, 1355
(Fed. Cir. 2006). In particular, a petitioner must show by preponderant evidence: (1) a
medical theory causally connecting the vaccination and the injury; (2) a logical
sequence of cause and effect showing that the vaccination was the reason for the
injury; and (3) a showing of proximate temporal relationship between vaccination and
injury in order to prove causation-in-fact. Althen v. Sec’y of Health & Human Servs.,
418 F.3d 1274, 1278 (Fed. Cir. 2005).
For both Table and Non-Table claims, Vaccine Program petitioners must
establish their claim by a “preponderance of the evidence”. § 300aa-13(a)(1). That is, a
petitioner must present evidence sufficient to show “that the existence of a fact is more
probable than its nonexistence . . . .” Moberly, 592 F.3d at 1322 n.2. Proof of medical
certainty is not required. Bunting v. Sec'y of Health & Human Servs., 931 F.2d 867,
872-73 (Fed. Cir. 1991). However, a petitioner may not receive a Vaccine Program
award based solely on his assertions; rather, the petition must be supported by either
medical records or by the opinion of a competent physician. § 300aa-13(a)(1). Once a
petitioner has established their prima facie case, the burden then shifts to respondent to
prove, also by preponderant evidence, that the alleged injury was caused by a factor
unrelated to vaccination. Althen, 418 F.3d at 1278 (citations omitted); § 300aa-
13(a)(1)(B).

II. Procedural History

Based on the allegations in the petition, this case was initially assigned to the
Chief Special Master as part of the Special Processing Unit (“SPU”), which is intended
to expedite cases having a high likelihood of informal resolution. (ECF Nos. 10, 12.)
The petition was accompanied by medical records and declarations marked as Exhibits
1-7. (ECF No. 1.) After the case was assigned to the SPU, petitioner filed additional
records marked as Exhibits 9-15. (ECF Nos. 15-17, 24-25, 28-29.)

Thereafter, a status conference was held with the Chief Special Master, during
which he advised that he felt there were factual issues to be resolved with respect to

3
petitioner’s alleged SIRVA. (ECF No. 33.) Following on from that discussion, petitioner
filed a motion for a ruling on the written record, seeking a finding that petitioner is
entitled to compensation for a Table SIRVA. (ECF No. 36.) Petitioner also filed an
additional declaration marked Exhibit 16. (ECF No. 34.) Respondent then filed his Rule
4(c) Report and a response to the motion, raising issues of injection situs, onset, and
symptoms inconsistent with SIRVA (specifically, numbness and tingling down to the
forearm). (ECF Nos. 39-40.) Respondent also contended that the medical records did
not demonstrate causation-in-fact. (Id.) Based on a preliminary review, the Chief
Special Master felt that it was “highly unlikely” petitioner could demonstrate a Table
SIRVA due primarily to the question of onset. (ECF No. 43, p. 2.) However, he felt it
might be possible that petitioner could demonstrate that her initial constellation of post-
vaccination symptoms (which were not reflective of SIRVA) “ultimately led to her later
SIRVA-like presentation.” (Id. at 4.) Thus, he reassigned the case to the undersigned
for further litigation. (Id. at 4-5; ECF No. 44.) Although he gave preliminary guidance,
the Chief Special Master did not rule on petitioner’s pending motion. (See ECF No. 43.)

After the case was reassigned, I issued an order denying petitioner’s motion for a
ruling on the written record without prejudice to refile. (Non-PDF Order, filed Jan. 23,
2024.) I explained that I did not feel the case was ripe for a ruling in light of the Chief
Special Master’s preliminary guidance. (Id.) Instead, I directed petitioner to file an
expert report supporting her claim. (Non-PDF Scheduling Order, filed Jan. 23, 2024.)
Petitioner then filed a report by Naveed Natanzi, D.O. (ECF No. 47; Exs. 17-39.)
Following this filing, I issued a Rule 5 Order. (ECF No. 50.) I advised the parties that,
based on my review, it appeared that Dr. Natanzi had challenged the Chief Special
Master’s preliminary assessment of onset rather than seeking to show that an initial
constellation of non-SIRVA symptoms had led to a later SIRVA-like sequela. (Id. at 2-
3.) I cautioned that I was inclined to agree with the Chief Special Master and that Dr.
Natanzi had not persuaded me otherwise. (Id. at 3.) I permitted a fact hearing to further
probe the question of onset. (Id. at 4.)

A fact hearing was held on August 2, 2024. (ECF No. 54; see Transcript of
Proceedings (“Tr.”), at ECF No. 57.) Petitioner and her daughter, Ms. Parker, testified.
(Tr. 5, 110.) In connection with the hearing, additional exhibits relating to the pharmacy
where petitioner was vaccinated were filed as Exhibits 40-42. (ECF Nos. 55, 64.)
Thereafter, the parties agreed that the case is ripe for written briefing pursuant to
Vaccine Rule 8(d). (ECF No. 66.) Petitioner then filed a motion for a ruling on the
written record. (ECF No. 67.) That motion is fully briefed. (ECF Nos. 68 (response)
and 69 (reply).)

In her motion, petitioner summarizes the record evidence and argues that it
supports a right-side administration of the subject vaccine followed by an injury that
satisfies the criteria for a Table Injury of SIRVA. (ECF No. 67.) Petitioner alternatively
asserts she should be found entitled to compensation for an injury caused-in-fact by her
vaccination (Id. at 10); however, the basis for this argument is not explained. In
response, respondent contends that a right-side administration is not preponderantly
supported, and that petitioner has neither demonstrated onset of shoulder pain within 48

4
hours of vaccination or that her alleged pain and reduced range of motion were limited
to her affected shoulder (i.e. SIRVA criteria (ii) and (iii)). (ECF No. 68.) Respondent
further contends that petitioner’s motion is inadequate to raise an alternative cause-in-
fact claim, which, in fact, was not pleaded in the petition. (Id. at 18-19.)

In light of the above, I have determined that the parties have had a full and fair
opportunity to develop the record and that it is appropriate to rule on the existing record.
See Vaccine Rule 8(d); Vaccine Rule 3(b)(2); Kreizenbeck v. Sec’y of Health & Human
Servs., 945 F.3d 1362, 1366 (Fed. Cir. 2020) (noting that “special masters must
determine that the record is comprehensive and fully developed before ruling on the
record”). Accordingly, petitioner’s motion is now ripe for resolution.

III. Summary of Record Evidence

Petitioner received the flu vaccination at issue at HyVee pharmacy on January
14, 2020. (Ex. 1, p. 1.) Prior to the vaccination, petitioner had issues with cholesterol,
blood pressure, mild depression and anxiety, agoraphobia,3 and stomach digestion.
(Tr. 7-8; Ex. 12, pp. 9-87.) Petitioner testified that she is afraid of receiving
vaccinations, but felt she needed to get the flu vaccine due to her advancing age and
her physician’s recommendation. (Tr. 10.) She decided to get the vaccine on a walk-in
basis while she was grocery shopping. (Id.)

The computer-generated receipt indicates that the vaccine was given
intramuscularly into the left arm. (Ex. 1, p. 1.) However, the consent form filled out by
hand by the administrator at the time of vaccination left the site of administration blank.
(Id. at 6.) Petitioner testified that she received her vaccination in her right arm. (Tr. 11,
42.) She further testified that, when she followed up with the pharmacy regarding the
incorrect record, she was told the “left” arm notation was a default.4 (Id. at 41, 96-97.)
Petitioner also testified the vaccine was administered “[r]eal high” and higher than she
normally would have expected, closer to the top of the shoulder than the deltoid. (Id. at
12-13.)

Petitioner described having a bad experience with the person who administered
her vaccination. (Tr. 11-14, 60-65.) Specifically, petitioner testified that she questioned
the administrator’s qualifications because she had perceived her as being young, about
19 or 20 years old. (Id. at 11, 62.) Thereafter, “she gave me a really, really, really nasty
3
Agoraphobia is an “intense, irrational fear of open spaces, characterized by marked fear of venturing out
alone or of being in public places where escape would be difficult, or help might be unavailable. It may be
associated with panic attacks.” Agoraphobia, DORLAND’S MEDICAL DICTIONARY ONLINE,
https://www.dorlandsonline.com/dorland/definition?id=1402 (last visited Nov. 19, 2025).
4
Petitioner’s suggestion that the pharmacy defaulted to documenting a left-side administration is
consistent with prior program experience. E.g., Hanna v. Sec’y of Health & Human Servs., No. 18-1455V,
2021 WL 3486248, at *8 (Fed. Cl. Spec. Mstr. July 15, 2021) (discussing prior cases where pharmacies
documented “left” arm administrations presumptively). However, it is not ultimately necessary to resolve
the site of injection in this case. In light of the analysis that follows, it is sufficient to assume, without
deciding, that petitioner received her vaccination in her right shoulder as alleged.

5
look, and she was mad. And she lifted up my shoulder and said, Yes, I’m a nursing
student,[5] and jabbed me, before, I mean, I could even say anything, because I wanted
it in my left arm, but she rolled up the sleeve of my right arm, jabbed it in . . . .” (Id. at
11.) Petitioner asserted that the administrator was “really mean” to her and jabbed the
needle in order to intentionally injure her. (Id. at 63, 69-70.) Petitioner testified that “I’ve
never had any pain like this in my life . . . and I know it went through a muscle or bone
or something, because I let out a scream. I was crying. People were looking.” (Id. at
11-12.) On cross-examination, however, petitioner conceded that she was not actually
crying, though she maintained that she felt embarrassed, presumably because of
having yelled out. (Id. at 70.) During cross examination, she admitted to having had an
exaggerated perception when she had suggested, as she did in later histories
discussed below, that the vaccine was administered using an unusually large needle,
attributing this to her fear of shots. (Id. at 84-85.) However, she denied that her fear
colored her impression of the interaction with the vaccine administrator. (Id.)

In later written statements and in her testimony, petitioner averred that she went
home directly from receiving the vaccination and confided in her adult daughter, who
lived with her, that she had a bad interaction with the vaccine administrator and that her
shoulder was very painful. (Tr. 13-14; Ex. 4, p. 1.) During the hearing, her daughter,
Ms. Parker, corroborated this aspect of petitioner’s account. (Tr. 111-14, 136-37.)
Notably, however, petitioner acknowledged during the hearing that she had drafted Ms.
Parker’s original written account. (Id. at 103 (discussing Ex. 5); see also id. at 120,
125.) Nonetheless, Ms. Parker asserted that “everything in this statement is correct.”6
(Id. at 120.) Shortly after arriving home, petitioner experienced a number of systemic
symptoms. (Id. at 15-16.)

Two days post-vaccination, on January 16, 2020, petitioner e-mailed her primary
care provider, with a subject line of “Non-Urgent Medical Question.” (Ex. 2, p. 1.)
Petitioner’s e-mail reported her systemic symptoms but included no discussion of any
arm or shoulder pain. (Id.) She wrote in full:

I went to get a flu shot 2nd time in my life I went tot [sic] Hy Vee on the 14th
at 5:00 PM. I went home and at 6:00 pm my body went into the worst pain
with all my bones aching violently. I started to shake all over and I could
not walk do to the shaking. After an hour I could not get air in my lungs it
was like they were collapsing. Then my heart started racing and then it
slowed and was irregular. Then my brain started to hurt it was a weird felling
[sic] and the headache was severe. My daughter wanted to take me to the
emergency room but I got in bed with 4 covers and she turned the heat up
and I fell asleep until 11:00 pm. I threw up 7 times and then I was coughing

5
As respondent stressed in questioning upon cross examination, the vaccine administration record
indicates the vaccine was administered by a pharmacist. (Ex. 1, pp.1, 6; Tr. 67-69.)
6
One reason for holding the fact hearing in this case was the undersigned’s concern that Ms. Parker’s
signed, written statement abruptly switched from describing the course of petitioner’s post-vaccination
reaction in the third person (as would be appropriate) to the first person, raising a credibility issue. (Ex. 5;
ECF No. 50 (Rule 5 Order).)

6
and could not stop. It was like I was going to cough up my lungs. I took a
triple dose of cough medicine and it stopped. I thought I was going to die
that night. I read on the info that Hy VEE gave me that it is inactive serum
and you can’t get the flu. I got all the signs of the flu in a compressed
amount of time. I was fine the next day. I just wanted you to know that I
will never take a flu shot again. I don’t understand why a person over 65
must take the 4 times the serum shot when I am 5 feet 1 inch tall and 135
pounds. Why would a 6 foot man weighing 250 pounds take the same
amount? It stands to reason I did not need that amount of serum. You don’t
have to respond to me. This was just for your info and maybe put in my file.
Thank You for listening.

(Id.)

During the hearing, petitioner was asked whether this description is accurate.
(Tr. 19-20.) She testified “Yes. This is, because, you know, sometimes it’s hard to
remember exactly everything from back then, but this is what I said. This is it.” (Id. at
20.) Petitioner testified that, by the morning following her vaccination (and therefore by
the time she wrote the e-mail to her physician), all of her symptoms had resolved except
her alleged shoulder pain, which she testified was “still very painful” and “what hurt the
most.” (Id. at 17.) However, regarding her shoulder pain, petitioner testified that “I
didn’t think it was that important to what I wanted to tell him about my reaction to the
shot he told me to get. And that to me was secondary when I was writing him this.” (Id.
at 23.) Based on the description in petitioner’s e-mail, the physician responded that “[i]t
does sound like you had a reaction to the flu,” which he characterized as “severe” and
therefore recommended petitioner not receive the vaccine again in the future.7 (Ex. 2,
p. 1.)

About two weeks later, petitioner presented to her primary care provider in
person on January 29, 2020. (Ex. 12, pp. 96-99.) The recorded history was as follows:

7
Significant attention was paid during the hearing to the fact that, despite stating that she believed she
was going to die, petitioner was not actually taken to the emergency department on the night of January
14, 2020. (E.g., Tr. 129-32.) In that regard, petitioner’s daughter, Ms. Parker, who was with her at the
time, testified that, despite being “terrified,” she knew the situation was not life-threatening and opted not
to seek medical attention because her mother has fear and anxiety regarding medical encounters. (Id. at
129-32, 134-35.) It was otherwise noted during the hearing that petitioner has a history of panic attacks
and that she took Xanax, which is prescribed for her anxiety, after her symptoms began. (Id. at 15, 17,
77, 112.) In that regard, petitioner testified that she never received any specific diagnosis for her
constellation of symptoms. (Id. at 17.) During the follow up encounter discussed below, her primary care
provider noted petitioner’s assessed vaccine reaction to have been nonallergic. (Ex. 12, p. 97.) On this
record, however, there is not sufficient evidence to suggest petitioner suffered a panic attack rather than
an adverse reaction to the vaccination, albeit nonallergic, as initially assessed by the treating physician.
Although the initial assessment was made without the benefit of a physical exam, the primary care
provider did have a longstanding treatment history with petitioner, including for her anxiety and
depression. (Tr. 8, 57, 137.)

7
Patient is here for an acute issue today. She had a flu shot on January 14.
It is important note this is only her second flu shot ever. She did get 1 in
2015. Within an hour of getting that shot she had what sounds like a fairly
nonallergic significant reaction to the shot. She had nausea and vomiting
and threw up about 7 times. She had fevers chills and sweats and what
sounds to be rigors. She had some difficulties with breathing and coughing.
She had unusual sensations in the right chest that moved to the left chest.
This lasted the entire night. The next morning she felt better and did not
have a fever after that. She started eating again. The only lasting thing is
that she feels more palpitations and is worried that her heart and lungs are
permanently damaged. She feels like her heart skips a beat. She has no
cough or shortness of breath. She denies any PND or orthopnea. She
sometimes will get numbness and tingling in the feet as well as at the end
of the day have swelling of the feet. She has not had precipitous weight
gain. She never wants to have a flu shot again.

(Id. at 97.) The physician recorded his plan as “reassurance,” noting that petitioner had
no evidence of either heart or lung damage, including an absence of premature
ventricular contractions on EKG and no signs of heart failure. (Id. at 99.) Although he
was willing to mark the flu vaccine as an allergy in petitioner’s record, he noted that he
did not believe any further work up was needed and remarked that “I do not think there
is anything to do now, I think she is much better. She agrees.” (Id.) The record of this
encounter includes a physical exam of petitioner’s extremities; however, there is no
explicit notation regarding petitioner’s upper extremities. (Id. at 98.)

Petitioner did not challenge the history recorded with the January 29, 2020
encounter. (Tr. 24-25, 81.) She testified that her shoulder was hurting at the time of
this encounter (Id. at 24); however, she could not recall whether she told her physician
about her alleged shoulder pain at this encounter and could not recall if her shoulder
was examined (Id. at 24, 88-89). Petitioner rationalized that she did not initially report
her shoulder pain to her physician, because she understood it to be a result of the poor
manner of administration and still felt it would go away. (Id. at 23, 25, 81-82.) Petitioner
could not recall at what point in time she ultimately became concerned that her shoulder
pain was persisting. (Id. at 30.) Yet, she testified on cross-examination that she knew
what she was experiencing was not normal post-vaccination arm soreness. (Id. at 82.)
In fact, petitioner testified that at the beginning, her pain was a nine on a ten-point scale.
(Id. at 38.) In that regard, petitioner testified that she returned to the pharmacy to
complain about her experience (which aspect is not clear) after only about three to four
days. (Id. at 40-43, 96-98.) As a result of her effort, she learned about the vaccine
injury program within about a week and a half of her vaccination. (Id. at 98.)

Petitioner did not seek medical care again until about four months later, on May
8, 2020, when she presented for a virtual visit while quarantining herself due to Covid-
19. (Ex. 12, pp. 109-14.) During the hearing, she confirmed the encounter was via
video conference. (Tr. 26.) The progress note indicates:

8
She continues to have pain numbness and tingling in her right shoulder after
a flu shot that was given in mid January. She had this done at Hy Vee and
really had a reaction to it it sounds like. She has limited range of motion of
her shoulder. She has no redness swelling or heat down the arm but she
does have a local spot laterally on the shoulder where the injection was
given. She tells me that the needle was bigger than usual that was used.
She does have numbness and tingling down to the mid forearm. She
otherwise feels okay systemically. No fevers chills or sweats. Appetite has
been fair. She is anxious because of the quarantine for COVID-19 that she
has been doing. She still smoking some. She does not want to come down
to the hospital or have any testing at this point in time, just mostly wants
reassurance. She also wants to know what she can do. Her pain is better
with Tylenol and rest. She thinks it is worse recently because she has been
trying to clean out her garage. Doing things that maybe she should not do.

(Ex. 12, p. 110.) Although this record seemingly indicates the encounter may have
been prompted by recent pain related to cleaning out her garage, petitioner sought
during the hearing to minimize the exertion involved in cleaning her garage, initially
suggesting that she had only done some sweeping (Tr. 27); however, she ultimately
noted that she did do at least some minimal lifting (Id. at 28-29). Petitioner testified that
the history she provided at this May 8, 2020 encounter is correct. (Id. at 25-26.)

The notation for physical exam of petitioner’s extremities notes “[n]o clubbing or
cyanosis and no edema. She does have limited range of motion with shoulder
abduction a little less than 90 degrees. No visible abnormalities of the shoulder on
exam otherwise. No redness heat or swelling.” (Ex. 12, p. 111.) The record does not
explain how range of motion was assessed given the virtual format. (See id.) During
the hearing, petitioner testified that the physician “asked me several questions. Raise
your arm. Where does it start hurting? And that’s what I did. (Tr. 31.) She said they
did “like two or three” maneuvers. (Id. at 32.) The neurologic exam noted “[h]er
strength appears normal in the upper extremities bilaterally and sensation seems to be
normal to light touch in the fingertips,” though, again, the manner in which this was
determined is not indicated. (Ex. 12, p. 111.) Petitioner was assessed as having
“[p]ossible shoulder injury related to vaccine administration.” (Id.) Specifically, the
physician remarked “I certainly told her that this is possible. I also worry about rotator
cuff pathology.” (Id. at 112.) However, petitioner did not want to pursue further testing
at that time and conservative treatment, including Tylenol, ice, heat, and rest, were
therefore recommended. (Id.) It was noted that “other options would involve coming
here and doing a complete shoulder exam and may be [sic] x-rays versus EMG/NCS
since there is some neuropathic flavor to her injury or even just a trial of gabapentin.”
(Id.) Petitioner was instructed to follow up in a month. (Id.)

Petitioner did not return for care until October 9, 2020, when she presented for
an annual wellness exam. (Ex. 3, pp. 7-12.) It was noted that overall petitioner was
“getting along fairly well.” (Id. at 8.) However, she reported that she “continues to have
mild numbness and pain in the right arm after receiving flu shot last winter. This is

9
slowly getting better.” (Id.) Otherwise, petitioner’s shoulder was not discussed.
Physical exam of petitioner’s extremities noted only the absence of clubbing, cyanosis,
and edema. (Id. at 10.) No further evaluation of petitioner’s alleged shoulder injury is
in evidence. Petitioner testified that she still experiences occasional numbness and
tingling all the way down her arm. (Tr. 94-95.) However, she confirmed that she has
not seen a neurologist for this complaint. (Id. at 95.)

Petitioner’s expert, Dr. Natanzi,8 opined that petitioner “described having severe
systemic reactions to and side effects of flu, which, in my opinion, more likely than not
also included a shoulder condition.” (Ex. 17, p. 3.) Dr. Natanzi noted four reasons for
this conclusion: (1) no other intervening event explains petitioner’s reported shoulder
pain; (2) it is common for patients to highlight only the most severe symptoms when
presenting with multiple symptoms occurring simultaneously; (3) the medical records
consistently attribute petitioner’s shoulder dysfunction to her flu vaccine whenever it is
mentioned; and (4) petitioner’s personal statements recall severe pain immediately after
vaccination. (Id.) In his conclusion, Dr. Natanzi stressed that “[t]his report is based on
[petitioner’s] recollection of events that are presumed to be accurate and have been
taken at face value.” (Id. at 5.)

Based on his assumption of immediate post-vaccination shoulder pain, Dr.
Natanzi opined that petitioner suffered a SIRVA. (Ex. 17, p. 3.) Dr. Natanzi
acknowledged that petitioner’s medical evaluations were limited and that she had no
orthopedic in-person examination and no MRI. (Id.) However, he noted that this was
likely due to pandemic-related restrictions and therefore, one should rely more heavily
on clinical cues and subjective complaints. (Id.) Specifically, based on the May 8, 2020
finding of a greater than 50% reduction in range of motion, Dr. Natanzi endorsed Dr.
Holm’s suspicion of either a SIRVA or rotator cuff pathology. (Id. at 3-4.) In that regard,
petitioner did testify that, because of her age, she “went into total panic and fear”
regarding the pandemic, which caused her to be hesitant to seek care. (Tr. 49.)

Dr. Natanzi acknowledged that petitioner’s symptoms of numbness and tingling
extending to her forearm “are not readily or commonly attributed to shoulder
pathologies,” but suggested that such symptoms can result from trigger points within the
rotator cuff. (Ex. 17, p. 4 (citing S. Atanasoff et al., Shoulder Injury Related to Vaccine
Administration (SIRVA), 28 VACCINE 8049 (2010) (Ex. 19); Gokcan Okur & Kimberly A.
Chaney, Magnetic Resonance Imaging of Abnormal Shoulder Influenza Vaccination, 43
SKELETAL RADIOLOGY 1325 (2014) (Ex. 27)).) Thus, because he opined that petitioner

8
Dr. Natanzi received his Doctor of Osteopathy in 2012 from Western University of Health Sciences. (Ex.
18, p. 2.) He completed a traditional rotating internship at Downey Regional Medical Center in Downey,
California in 2013. (Id.) Dr. Natanzi went on to complete his residency in physical medicine and
rehabilitation at the University of California, Irvine in 2016, serving as chief resident in his final year. (Id.
at 1.) Thereafter, he trained at Bodor Clinic in Napa, California, in 2017. (Id.; Ex. 17, p. 1.) Dr. Natanzi is
board-certified in physical medicine and rehabilitation and pain management, and he maintains his
license to practice medicine in California. (Ex. 18, pp. 1, 4.) Currently, he serves as a staff physician at
VA Long Beach Healthcare System and is the founder of the Regenerative Sports and Spine Institute in
Sherman Oaks, California. (Ex. 17, p. 1; Ex. 18, p. 1.) In his current practice, Dr. Natanzi almost
exclusively treats patients with musculoskeletal issues. (Ex. 17, p. 1.)

10
experienced injection-related rotator cuff and bursal injuries, he is willing to attribute
petitioner’s seeming neurologic symptoms to her alleged SIRVA. (Id.) Dr. Natanzi’s
opinion does not clearly, but could arguably, encompass an opinion with respect to
causation-in-fact; however, any such opinion is based on the same temporal
relationship upon which he relied in opining that a Table SIRVA was present. (Id. at 3-
5.)

IV. Discussion

a. SIRVA QAI (1) – No history of pain, inflammation or dysfunction of the
affected shoulder

The first SIRVA criterion requires that there be no relevant prior history of
shoulder concerns that could explain the post-vaccination symptoms. In this case, there
has been no suggestion that petitioner had any such history. (See ECF No. 68, p. 11.)
Nor does my own review of the record evidence suggest petitioner’s prior medical
history includes any relevant conditions or symptoms affecting her right shoulder.

b. SIRVA QAI (2) – Pain occurs within the specified time-frame (i.e. 48
hours)

The second SIRVA criterion requires that the petitioner experience an onset of
shoulder pain within 48 hours of the vaccination at issue. This is the most thoroughly
contested point in this case.

Petitioner argues that she has demonstrated that the onset of her shoulder pain
occurred within 48 hours of her vaccination. (ECF No. 67, pp. 2-3, 10.) She relies
primarily on her own testimonial statements, which she argues are corroborated by her
daughter’s testimony. (Id. at 2-3, 5, 10.) She disagrees with respondent’s
characterization of the testimony offered in this case. (ECF No. 69, pp. 6-9.) She also
seems to suggest that her medical records should be viewed as supporting her claim,
stressing that her e-mail to her doctor and initial treatment record from January 29, 2020
broadly support the fact of a significant vaccine reaction and that her later May 8, 2020
encounter more explicitly identifies her shoulder pain as a part of that condition. (ECF
No. 67, p. 3 (discussing Ex. 2, p. 1; Ex. 12, pp. 97, 99, 110).) She notes in particular
that the May 8, 2020 record documents “a local spot laterally on the shoulder” as the
site of injection. (Id. at 3, 7, 10 (citing Ex. 12, p. 110).) She also explains that she did
not initially report her shoulder pain because she understood it to be due to a bad
administration and expected the pain to persist for some time. (Id. at 6.) Otherwise,
petitioner stresses that the limitations of her medical evaluations, and her delay in
seeking treatment specifically for her shoulder, are explained by her agoraphobia and
the Covid-19 pandemic. (Id. at 3-4, 6-7.)

Respondent argues, however, that petitioner and her daughter did not provide
the type of compelling testimonial evidence that could have overcome her
contemporaneous medical records, suggesting the testimony was susceptible to

11
exaggeration and credibility concerns. (ECF No. 68, p. 13.) Respondent notes a
number of inconsistencies between petitioner’s account and her daughter’s account.
(Id. at 13-14.) Respondent stresses that the contemporaneous medical records show
that petitioner not only waited four months to report her alleged shoulder pain, but that
she also failed to mention it at in-person medical encounters occurring in the meantime.
(Id. at 14 (citing Stryski v. Sec’y of Health & Human Servs., No. 20-1177V, 2022 WL
17820775 (Fed. Cl. Spec. Mstr. Oct. 17, 2022); Bulman v. Sec’y of Health & Human
Servs., No. 19-1217V, 2021 WL 4165349 (Fed. Cl. Spec. Mstr. Aug. 12, 2021)).)

The process for making determinations in Vaccine Program cases regarding
factual issues begins with consideration of the medical records. § 300aa-11(c)(2). The
special master is required to consider “all [ ] relevant medical and scientific evidence
contained in the record,” including “any diagnosis, conclusion, medical judgment, or
autopsy or coroner's report which is contained in the record regarding the nature,
causation, and aggravation of the petitioner's illness, disability, injury, condition, or
death,” as well as “the results of any diagnostic or evaluative test which are contained in
the record and the summaries and conclusions.” § 300aa-13(b)(1)(A)-(B). However,
the special master is then required to weigh all of the evidence presented. See 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
contemporaneous medical records than to other evidence). The special master is
obligated to consider and compare the medical records, testimony, and all other
“relevant and reliable evidence” contained in the record. La Londe v. Sec’y of Health &
Human Servs., 110 Fed. Cl. 184, 204 (2013) (quoting Vaccine Rule 8) (citing § 300aa-
12(d)(3)), aff’d sub nom., LaLonde v. Sec’y of Health & Human Servs., 746 F.3d 1334
(Fed. Cir. 2014); see also Burns, 3 F.3d at 416-17. Thus, for example, the Vaccine Act
explicitly instructs that a special master may find the time period for the first symptom or
manifestation of onset required for a Table Injury is satisfied “even though the
occurrence of such symptom or manifestation was not recorded or was incorrectly
recorded as having occurred outside such period.” § 300aa-13(b)(2). However, such a
finding must in all events be supported by preponderant evidence. Id.

The Federal Circuit has held that contemporaneous medical records are
ordinarily to be given significant weight due to the fact that “[t]he 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). Thus, 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 *19 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this
rule is not absolute. There is no presumption that medical records are accurate or
complete as to all of a patient’s physical conditions. Kirby v. Sec’y of Health & Human
Servs., 997 F.3d 1378, 1383 (Fed. Cir. 2021). Afterall, “medical records are only as
accurate as the person providing the information.” Parcells v. Sec’y of Health & Human
Servs., No. 03-1192V, 2006 WL 2252749, at *2 (Fed. Cl. Spec. Mstr. July 18, 2006).

12
“[T]he absence of a reference to a condition or circumstance is much less significant
than a reference which negates the existence of the condition or circumstance.”
Murphy v. Sec’y of Health & Human Servs., 23 Cl. Ct. 726, 733 (1991), aff’d per curiam,
968 F.2d 1226 (Fed. Cir. 1992), cert. denied, Murphy v. Sullivan, 506 U.S. 974 (1992).
When witness testimony is offered to overcome the weight generally afforded to
contemporaneous medical records, such testimony must be “consistent, clear, cogent[,]
and compelling.” Camery v. Sec’y of Health & Human Servs., 42 Fed. Cl. 381, 391
(1998) (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-2808V, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). Further, a special master must
consider the credibility of the individual offering the testimony. See Andreu v. Sec’y of
Health & Human Servs., 569 F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of
Health & Human Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).

In this case, I find that the contemporaneous medical records, namely petitioner’s
e-mail to her primary care provider of January 16, 2020 (Ex. 2), and her in-person follow
up encounter of January 29, 2020 (Ex. 12, pp. 96-99), which do not identify the
presence of any arm or shoulder pain, are due substantial weight, greater weight than
can be placed on the later medical records. Moreover, I do not find the testimonial
evidence credible enough to outweigh these contemporaneous records. There are
several reasons for these conclusions.

As a threshold matter, there is no dispute that the contemporaneous records are
accurate. Petitioner testified of her initial January 16, 2020 e-mail to her physician “this
is what I said. This is it.” (Tr. 20.) Indeed, petitioner specifically testified that it was the
best available recollection of what had occurred. (Id. (stating “sometimes it’s hard to
remember exactly everything from back then, but this is what I said”).) Moreover, I
place still further weight on this initial e-mail because it represents petitioner’s own
firsthand account. Demitor v. Sec’y of Health & Human Servs., No. 17-564V, 2019 WL
5688822, at *10 (Fed. Cl. Spec. Mstr. Oct. 9, 2019) (finding significance in a history
derived from petitioner’s own handwritten intake form, meaning “it cannot be said to
reflect any transcription mistake or miscommunication on the part of the [provider] or his
office. Nor can petitioner reasonably suggest that she was incompletely or incorrectly
paraphrased.”) Petitioner likewise did not contest that the history she provided at her in-
person follow up on January 29, 2020 was accurate. (Tr. 24-25, 81.) Moreover, she did
not at any time assert that, despite these records, she had reported shoulder pain to her
physician. Instead, she confirmed that she did not include such a report in her initial e-
mail and could not recall whether she raised the issue at her January 29, 2020
encounter. (Id. at 23-25, 87-89.)

Furthermore, the contemporaneous records represent detailed, consistent, and
seemingly complete, accounts of petitioner’s initial vaccine reaction, which include no
report of shoulder pain. Petitioner’s initial e-mail account from very shortly after her
reaction was an extensive description of her experience, including hour by hour
accounting of her vaccination, return home, and onset of symptoms, even indicating the
precise number of times petitioner vomited. (Ex. 2, p. 1.) She followed up with an in-
person checkup just two weeks later. (Ex. 12, pp. 96-99.) And, notably, while there

13
was no explicitly documented upper extremity exam, the record does confirm that a
physical exam of the lower extremities was conducted that correlated with the history
that had been provided. (Compare id. at 97 (history noting numbness, tingling, and
swelling of the feet), with id. at 98 (physical exam of the extremities examining lower
extremities up to the knee and noting a lack of clubbing, cyanosis, or edema).)
Moreover, the purpose of the encounter was to discuss petitioner’s concern that she
had ongoing “permanent” damage from her vaccine reaction. (Id. at 97.) However, the
record ultimately explains “I do not think there is anything to do now, I think she is much
better. She agrees.” (Id. at 99.) Thus, these records are not merely silent as to the
presence of shoulder pain. The January 29, 2020 in-person encounter and physical
exam contradict the notion of such a complaint given that petitioner had a holistic in-
person examination by a primary care provider targeted toward assessing post-
vaccination sequela she had reported and the resulting record confirms that both she
and her treating physician agreed her condition was resolved and that no further work-
up was required. (Id.) Moreover, in testimony, petitioner agreed broadly that the
January 29, 2020 exam included her extremities. (Tr. 81.)

I have also considered that petitioner’s later encounter record of May 8, 2020
includes a history that nonetheless attributed right shoulder pain to “a flu shot that was
given in mid January.” (Ex. 12, p. 110.) As with the prior records, petitioner testified
that this record is accurate. (Tr. 25-26.) However, this record is further removed from
the events at issue and, as a general matter, later histories are often given less weight.
See, e.g., R.K. v. Sec’y of Health & Human Servs., No. 03-0632V, 2015 WL 10936124,
at *76 (Fed. Cl. Spec. Mstr. Sept. 28, 2015) (holding that more remote histories of
illness do not have sufficient indicia of reliability to be credited over conflicting
contemporaneous medical records and earlier reported histories), mot. for rev. denied,
125 Fed Cl. 57 (2016), aff’d, 671 F. App’x 792 (Fed. Cir. 2016); see also Vergara v.
Sec’y of Health & Human Servs., No. 08-882V, 2014 WL 2795491, *4 (Fed. Cl. Spec.
Mstr. May 15, 2014) (“Special Masters frequently accord more weight to
contemporaneously-recorded medical symptoms than those recounted in later medical
histories, affidavits, or trial testimony” (emphasis added).). Additionally, the record
strongly suggests that the encounter was prompted by a recent change in petitioner’s
condition, which clouds the purported association to her prior vaccination. Specifically,
it noted of petitioner’s reported arm and shoulder complaints that “[s]he thinks it is worse
recently because she has been trying to clean out her garage.” (Ex. 12, p. 110.) And,
in any event, the history is no more specific than to indicate that petitioner experienced
shoulder pain some time “after” her vaccine and that petitioner associated the pain with
the vaccination. (Id.) Given the existence of the January 16, 2020 and January 29,
2020 records, and especially the fact that the January 29 record reflects an in-person
examination, this use of the term “after” is inadequate to evidence an onset of shoulder
pain occurring specifically within 48 hours of vaccination. Petitioner argues, in effect,
that the earlier records of January 16 and 29 should be read in harmony with the later
May 8, 2020 record, because, although they do not explicitly mention shoulder pain,
they confirm her initial adverse reaction to the vaccine. (See ECF No. 67, pp. 2-3.)
However, this begs the very question of whether the vaccine reaction included any
shoulder pain. Notably, not even petitioner considers the shoulder pain to have been a

14
part of the systemic adverse reaction she had previously reported. Instead, she testified
that she attributed the shoulder pain directly to the manner of injection. (Tr. 23, 25, 69-
70, 81-82.)

Additionally, the testimony offered in this case is not credible enough to outweigh
the contemporaneous medical records. In particular, there are internal tensions within
petitioner’s own stated rationale for her actions. For example, on the one hand,
petitioner testified that her delay in seeking treatment should be attributed to her
agoraphobia as well as the Covid-19 pandemic, which caused her to hesitate to seek
care for her shoulder. (Tr. 29-30, 49.) On the other hand, petitioner testified that she
knew immediately that her alleged shoulder pain was not normal post-vaccination arm
soreness (Id. at 82.) and she did, in fact, subsequently present for care of her vaccine
reaction on January 29, 2020 (Ex. 12, pp. 96-99). Thus, the fact that petitioner did not
report her alleged arm and shoulder pain on January 29 at her already-occurring in-
person appointment cannot be explained by either her agoraphobia or any
misperception that her pain was mere post-vaccination soreness rather than an actual
injury.

Petitioner further testified that she did not include her shoulder pain in her initial
e-mail to her physician because it was of secondary importance. (Tr. 23.) In that
regard, Dr. Natanzi similarly endorsed the notion that patients report only the most
severe symptoms. (Ex. 17, p. 3.) However, petitioner also testified, in effect, that at the
time she wrote the e-mail, her shoulder pain was her only remaining symptom and was
“still very painful” and “what hurt the most.” (Tr. 17.) She also testified that the injury
was extremely painful, noting that she had “never had any pain like this in my life.” (Id.
at 11.) She indicated that her shoulder pain was a nine on a ten-point pain scale. (Id.
at 38.) Moreover, although she was clear in testifying that her alleged shoulder pain
was not a part of the systemic reaction she suffered (Id. at 23, 25), she did otherwise
testify that she believed the pain resulted from a deliberate attempt to injure her (Id. at
63, 69-70). Thus, even accepting that petitioner could have had a narrower purpose in
writing the January 16, 2020 e-mail, it is still very difficult to square petitioner’s
perception that she had been injured (deliberately so), resulting in the worst pain of her
life, with her complete inaction in terms of seeking medical treatment for that injury. To
the extent petitioner testified that she initially felt the injury would resolve on its own (Id.
at 25), she was unable to recall when she became concerned that the pain was
persisting (Id. at 30).9

9
Additionally, without doubting that petitioner’s vaccination was a negative experience for her, I find that
petitioner’s vivid account of her vaccination experience is not entirely persuasive. Notably, petitioner
testified that she has fear and anxiety regarding medical encounters generally and vaccine administration
in particular. (E.g., Tr. 10.) Although she denied that her fear and anxiety colored her impression of her
vaccine administration (Id. at 84-85), she did at a minimum acknowledge that her perception of the
injection needle was likely exaggerated (Id. at 84). Moreover, while she initially described herself as
crying as a result of the injection, she conceded on cross-examination that she had not actually cried.
(Compare id. at 11-12, with id. at 70.) Thus, it is difficult to take this account entirely at face value.
Certain aspects of petitioner’s account, while not refuted on this record, are difficult to accept, without
corroboration, as recollections likely to be accurate, including her assertion that the vaccine administrator
was a nursing student, that the administrator “lost it,” that the administrator intentionally harmed her, that

15
Finally, I have considered that both petitioner and her daughter testified that
petitioner came home after this vaccination encounter and immediately reported
significant shoulder pain prior to the onset of her systemic vaccine reaction. (Tr. 14,
111.) However, even setting aside the inconsistencies argued by respondent, I remain
concerned that Ms. Parker’s original written account of the events of January 14, 2020,
which was in itself less clear as to the presence of shoulder pain versus injection site
swelling, was drafted in the first instance by petitioner, a point that was confirmed by
both witnesses during the hearing. (Id. at 102-03, 119-21, 124-26 (discussing Ex. 5).)
Moreover, although neither witness could recall precisely when the document was
created (Id. at 101-03, 120-21), Ms. Parker confirmed that it was for purposes of
litigation relative to petitioner’s alleged shoulder injury (Id. at 121, 128-29). Thus, to the
extent Ms. Parker’s testimony follows from the substance of the prior written statement,
I am unable to discern the extent to which it reflects a true independent recollection of
events. To be clear, this is not to doubt that petitioner suffered some form of systemic
reaction after she got home. That is corroborated by contemporaneous documentation
in the form of petitioner’s January 16, 2020 e-mail. (Ex. 2.) The only issue is whether
Ms. Parker’s testimony corroborates specifically that petitioner was also experiencing
shoulder pain at that time, which was not contemporaneously recorded. As noted
above, petitioner testified that the January 16, 2020 e-mail, which did not discuss
shoulder pain, and which predated any of the other testimonial statements, written or
oral, was the best available recollection of events. (Tr. 20 (stating “sometimes it’s hard
to remember exactly everything from back then, but this is what I said”).)

For all these reasons, there is not preponderant evidence that petitioner suffered
an onset of right shoulder pain within 48 hours of the administration of the subject
vaccination.

c. SIRVA QAI (3) – Pain and reduced range of motion are limited to the
shoulder in which the intramuscular vaccine was administered

The third SIRVA criterion requires that the post-vaccination pain and reduced
range of motion be limited to the affected shoulder. This requirement encompasses an
affirmative showing that the petitioner’s presentation included a reduction in range of
motion. Bolick v. Sec'y of Health & Human Servs., No. 20-893V, 2023 WL 8187307, at
*6-8 (Fed. Cl. Spec. Mstr. Oct. 19, 2023). Otherwise, as I have previously explained at
greater length in a prior decision, “the gravamen of this requirement is to guard against
compensating claims involving patterns of pain or reduced range of motion indicative of
a contributing etiology beyond the confines of a musculoskeletal injury to the affected
shoulder.” Grossmann v. Sec’y of Health & Human Servs., No. 18-00013V, 2022 WL
779666, at *15 (Fed. Cl. Spec. Mstr. Feb. 15, 2022) (citing Werning v. Sec’y of Health &
Human Servs., No. 18-0267V, 2020 WL 5051154, at *10 (Fed. Cl. Spec. Mstr. July 27,
2020)).

the vaccine administrator forcefully rolled up her sleeve, and that she received the vaccination standing
up. (Id. at 11, 62-65, 69-70.)

16
Although petitioner never had an in-person examination of her range of motion in
her shoulder, respondent does not challenge the presence of reduced range of motion.
(ECF No. 68, p. 18.) Instead, he argues that the evidence, particularly petitioner’s
testimony, indicates that petitioner had pain, numbness, and tingling, extending all the
way down her forearm, which he argues is incompatible with SIRVA. (Id. (citing Tr.
95).) Respondent cites two cases to support this argument. (Id. (citing Handley v.
Sec’y of Health & Human Servs., No. 21-1194V, 2024 WL 1328709 (Fed. Cl. Spec.
Mstr. Feb. 21, 2024); Blevins v. Sec’y of Health & Human Servs., No. 21-0385V, 2024
WL 1009562 (Fed. Cl. Spec. Mstr. Jan. 12, 2024). Petitioner argues that the cases
cited by respondent are distinguishable based on the extent of the neck and back pain
involved in those cases. (ECF No. 69, pp. 9-10.) She argues that she “has not
complained of pain outside her right shoulder – it has always been limited to her right
shoulder. While Petitioner testified that she has some numbness radiating down her
right arm at times, such numbness is associated with her right shoulder injury.” (Id. at
10.)

Petitioner is not persuasive in contending that only her numbness, and not her
reported pain, extended beyond the shoulder. While it is true that the history she
provided on May 8, 2020 does not clearly identify pain (as opposed to numbness and
tingling) extending beyond the shoulder (Ex. 12, p. 110), her subsequent encounter
record several months later specifically noted that she “continues to have mild
numbness and pain in the right arm after receiving flu shot last winter” (Ex. 3, p. 8; see
also Tr. 33-34 (endorsing the accuracy of the notation); Ex. 11, p. 3 (stating “[m]y right
arm is causing me pain”)). In that regard, the affidavit petitioner submitted with her
petition states “[s]ince receiving the vaccine, I have experienced significant pain,
weakness, numbness, and limited range of motion in my right shoulder and arm.” (Ex.
7, ¶ 5 (emphasis added).)

Nonetheless, as noted above, the key question is whether the pattern of pain and
reduced range of motion is indicative of an etiology beyond the shoulder itself.
Grossman, 2022 WL 779666, at *15. Here, petitioner’s treating physician felt that a
SIRVA was only one “possible” explanation for her symptoms. (Ex. 12, pp. 111-12.) He
otherwise remained concerned, especially in the absence of a complete in-person
shoulder exam, that petitioner’s reported symptoms had a “neuropathic flavor.” (Id. at
112.) Although petitioner’s expert, Dr. Natanzi, was more willing to conclude that these
symptoms were sequela of her alleged SIRVA, he likewise acknowledged that they “are
not readily or commonly attributed to shoulder pathologies.” (Ex. 17, pp. 3-4.)

Additionally, although respondent did not raise the issue, I remain concerned that
petitioner’s alleged reduced range of motion is not preponderantly demonstrated. Of
course, the fact that petitioner did not undergo an in-person evaluation on May 8, 2020
is readily explained by the Covid-19 pandemic. I stress that I do not fault petitioner for
resorting to a telehealth encounter and that I do give some weight to the remote findings
that resulted from the May 8, 2020 encounter as evidence of her condition at the time.
However, especially given the other issues as to onset and symptoms beyond the

17
shoulder, I cannot overlook the treating physician’s notation that “I told her other options
would involve coming here and doing a complete shoulder exam and may be x-rays
versus EMG/NCS since there is some neuropathic flavor to her injury . . . .” (Ex. 12, p.
112.) This evidences that petitioner’s treating physician was not comfortable that the
telehealth encounter was sufficient to diagnose her condition as a shoulder injury based
on her reported symptoms and only a remote demonstration of reduced range of
motion.

Prior decisions have explained that a petitioner’s burden of proof under the third
SIRVA criterion is to show “actual, demonstrated movement limitations” whereas “a
reluctance to move one’s arm or shoulder due to pain is not equivalent.” Petty v. Sec’y
of Health & Human Servs., 19-1332V, 2024 WL 5381961, at *4 (Fed. Cl. Spec. Mstr.
Sept. 24, 2024) (emphasis omitted); see also McNally v. Sec’y of Health & Human
Servs., No. 20-1763V, 2024 WL 4024429, at *4 (Fed. Cl. Spec. Mstr. July 31, 2024)
(explaining the petitioner’s report of reduced range of motion “was not corroborated by
any actual exam. Indeed, no ROM limits were demonstrated at any of petitioner’s in-
person visits with Dr. Wetters. Otherwise, Petitioner only displayed pain with shoulder
movement.” (emphasis omitted)). Here, although petitioner testified that she performed
two to three different maneuvers for her physician via video, she explained that he
“asked me several questions. Raise your arm. Where does it start hurting? And that’s
what I did.” (Tr. 31-32.) Thus, by petitioner’s own account, her exam would only have
ascertained pain with movement. No other explicit range of motion determination is
included in any of the medical records.

For all these reasons, there is not preponderant evidence that petitioner suffered
pain and reduced range of motion limited to the affected shoulder.

d. SIRVA QAI (4) – No other condition or abnormality is present that would
explain the patient’s symptoms.

The fourth SIRVA criterion requires that “[n]o other condition or abnormality is
present that would explain the patient’s symptoms (e.g. NCS/EMG or clinical evidence
of radiculopathy, brachial neuritis, mononeuropathies, or any other neuropathy).” 42
C.F.R. § 100.3(c)(10)(iv). This element of petitioner’s showing “requires consideration
of a petitioner’s medical condition as a whole.” Record v. Sec’y of Health & Human
Servs., 175 Fed. Cl. 673, 680 (2025). While the “other condition or abnormality” at
issue must qualify as an explanation for the petitioner’s symptoms, it “need not be a
better or more likely explanation.” French v. Sec’y of Health & Human Servs., No. 20-
0862V, 2023 WL 7128178, at *6 (Fed. Cl. Spec. Mstr. Sept. 27, 2023). Indeed, a
petitioner may fail to meet the fourth SIRVA criterion even where there is clinical
evidence of an alternative condition that falls short of a definitive diagnosis. Durham v.
Sec’y of Health & Human Servs., No. 17-1899V, 2023 WL 3196229, at *13-14 (Fed. Cl.
Spec. Mstr. May 2, 2023) (noting that the regulation cites “clinical evidence of” various
conditions). Ultimately, where the presence of another condition is apparent, petitioner
bears the burden of proving that the condition nonetheless “would not explain” her
symptoms. Id. at *14.

18
Neither party paid significant attention to the fourth SIRVA criterion. However,
the conclusion relative to this criterion necessarily follows from the analyses in the two
preceding sections. Petitioner does not have any other definitively diagnosed condition
that would explain her symptoms. However, as discussed in the preceding section, she
consistently reported her shoulder pain as occurring in the context of pain, numbness,
and tingling, running down her arm. Her primary care provider felt that these symptoms
were “neuropathic in flavor” and recommended a follow up EMG/NCS. (Ex. 12, p. 112.)
Despite this, and despite acknowledging that petitioner’s symptoms “are not readily or
commonly attributed to shoulder pathologies,” Dr. Natanzi was willing to opine that
petitioner’s own symptoms were sequela of her SIRVA. (Ex. 17, pp. 3-4.) However,
this opinion was based on a close temporal relationship between vaccination and pain
onset as well as Dr. Natanzi’s accepting of petitioner’s May 8, 2020 telehealth
appointment as confirmation of a rotator cuff and bursal pathology. (Id.) In light of the
analysis in the two preceding sections, neither of these assumptions is preponderantly
supported. Accordingly, petitioner does have “clinical evidence of” neuropathy that
would potentially explain her symptoms, as was noted by her treating physician.

For all these reasons, there is not preponderant evidence that petitioner is free of
any other condition or abnormality that would explain her symptoms.

e. Causation-in-fact

In her motion for a ruling on the written record, although she overwhelmingly
focuses on asserting a Table SIRVA claim, petitioner also states that “[a]lternatively, if
the Court believes this claim is more properly categorized as an ‘Off Table’ claim,
Petitioner requests judgment in her favor for an ‘Off Table’ claim based on the same
evidence outlined above.” (ECF No. 67, p. 10.) Importantly, however, petitioner did not
explain in her motion what injury she alleges to have been caused-in-fact by her
vaccination. Nor did she plead any such injury in her petition.

Petitioner “must specify [her] vaccine-related injury and shoulder the burden of
proof on causation.” Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339,
1346 (Fed. Cir. 2010). “Although the Vaccine Act does not require absolute precision, it
does require the petitioner to establish an injury – the Act specifically creates a claim for
compensation for ‘vaccine-related injury or death.’” Stillwell v. Sec’y of Health & Human
Servs., 118 Fed. Cl. 47, 56 (2014) (emphasis omitted) (quoting 42 U.S.C. § 300aa-
11(c)). In order to present an “injury” cognizable under the Vaccine Act, “[m]edical
recognition of the injury claimed is critical” and petitioner must assert “more than just a
symptom or manifestation of an unknown injury.” Broekelschen, 618 F.3d at 1349. As
explained above, due to the significant limitations in her medical evaluations, the nature
of petitioner’s right arm and shoulder complaints, and whether they are due to a
musculoskeletal or neurologic cause, remains unclear. Even accepting that petitioner
likely experienced some form of transient systemic adverse reaction to her vaccination,
that condition does not satisfy the statutory severity requirement standing alone. The

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symptoms resolved by the next day and petitioner did not experience inpatient
hospitalization and surgical intervention as a result.

During the pendency of this case, petitioner was invited to explore whether she
could link her later-reported shoulder symptoms to that initial constellation of systemic
symptoms, but she did not succeed in doing so. Instead, Dr. Natanzi sought to opine
that petitioner’s shoulder injury began at the same time as her constellation of systemic
symptoms. In so doing, Dr. Natanzi predicated his medical opinion on the assumption
that petitioner’s shoulder symptoms began within 48 hours of vaccination, which I have
found is not preponderantly supported. Therefore, his opinion is not credited. Burns, 3
F.3d at 417 (holding that “[t]he special master concluded that the expert based his
opinion on facts not substantiated by the record. As a result, the special master
properly rejected the testimony of petitioner's medical expert.”); Dobrydnev v. Sec’y of
Health & Human Servs., 566 F. App’x 976, 982-83 (Fed. Cir. 2014) (holding that the
special master was correct in noting that “[w]hen an expert assumes facts that are not
supported by a preponderance of the evidence, a finder of fact may properly reject the
expert’s opinion” (alteration in original) (quoting Dobrydneva v. Sec’y of Health &
Human Servs., No. 04-1593V, 2010 WL 8106881, at *9 n.12 (Fed. Cl. Spec. Mstr. Oct.
27, 2010), rev’d, 98 Fed. Cl. 190 (2011), rev’d sub nom., Dobrydnev v. Sec’y of Health
& Human Servs., 566 F. App’x 976, 982-83 (Fed. Cir. 2014)) (citing Brooke Group Ltd.
v. Brown & Williamson Tobacco Corp., 509 U.S. 209, 242 (1993))); Bushnell v. Sec'y of
Health & Human Servs., No. 02-1648V, 2015 WL 4099824, at *12 (Fed. Cl. Spec. Mstr.
June 12, 2015) (finding that “because Dr. Marks' opinion is based on a false assumption
regarding the onset of J.R.B.'s condition, and the incorrect assumption of a ‘stepwise
regression’ after each vaccine administration, it should not be credited”).

Petitioner’s primary care physician likewise suggested petitioner may have a
“possible” shoulder injury related to vaccine administration. (Ex. 12, p. 111.) However,
this was, at best, a tentative conclusion, as it is apparent from the medical record that
he had not ruled out a neurologic cause for petitioner’s condition. (Id. at 112 (noting the
lack of a complete physical exam and describing the reported injury as having a
“neuropathic flavor”).) While I appreciate that petitioner has a strongly held view that
her symptoms are related to her vaccination, it is she who bears the burden of proof and
the Federal Circuit has explained that “[a]lthough probative, neither a mere showing of a
proximate temporal relationship between vaccination and injury, nor a simplistic
elimination of other potential causes of the injury suffices, without more, to meet the
burden of showing actual causation.” Althen, 418 F.3d at 1278. Thus, “[a] treating
physician’s recognition of a temporal relationship does not advance the analysis of
causation.” Isaac v. Sec’y of Health and Human Servs., No. 08-601V, 2012 WL
3609993, at *26 (Fed. Cl. Spec. Mstr. July 30, 2012). And, in any event, even if
accepting the treater’s impression as a clear diagnosis, it would still be based on the
same close temporal relationship as assumed by Dr. Natanzi.

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V. Conclusion

Petitioner clearly suffered and she does have my sympathy. However, for all the
reasons discussed above, there is not preponderant evidence of any compensable
injury under the standards set by this program. Therefore, pursuant to § 300aa-
12(d)(3)(A) and Vaccine Rule 10, this decision concludes that petitioner is not entitled to
an award of compensation. Absent a timely motion for review, the Clerk is directed to
enter judgment dismissing this case for insufficient proof in accordance with Vaccine
Rule 11(a).

IT IS SO ORDERED.

s/Daniel T. Horner
Daniel T. Horner
Special Master

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11224919. Public record. Not legal advice.