Martin v. Secretary of Health and Human Services

In the United States Court of Federal Claims

OFFICE OF SPECIAL MASTERS

No. 21-2220V

Filed: December 5, 2025

Special Master Horner

RONALD MARTIN,

Petitioner,

v.

SECRETARY OF HEALTH AND

HUMAN SERVICES,

Respondent.

Leah VaSahnja Durant, Law Offices of Leah V. Durant, PLLC, Washington, DC, for

petitioner.

Meghan Murphy, U.S. Department of Justice, Washington, DC, for respondent.

RULING ON ENTITLEMENT1

On November 29, 2021, petitioner filed a petition under the National Childhood

Vaccine Injury Act (“Vaccine Act”), 42 U.S.C. § 300aa-10, et seq. (2012).2 In the initial

petition, he alleged a Table Injury of “SIRVA,” i.e. a shoulder injury related to vaccine

administration, as well as polymyalgia rheumatica (“PMR”), resulting from an influenza

(“flu”) vaccination he received on October 1, 2019. (ECF No. 1.) However, he later filed

an amended petition narrowing his claim to the alleged shoulder injury and specifying

that he was pursuing that shoulder injury claim on a “causation in fact” basis or,

alternatively, as a significant aggravation claim. (ECF No. 19.)

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

For the reasons set forth below, I conclude that petitioner is entitled to

compensation for a shoulder injury caused in fact by his vaccination.

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

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); § 300aa-11(c)(1)(C)(i); § 300aa-14(a); § 300aa-

13(a)(1)(B).

As relevant here, the Vaccine Injury Table lists a Shoulder Injury Related to

Vaccine Administration or “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” (“QAIs”), which

provide a 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,” petitioner must show that his 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:

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(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

(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, or any other

neuropathy).

42 C.F.R. § 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 (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). 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).

3

II. Procedural History

Petitioner initially filed medical records and an affidavit marked as Exhibits 1-14.

(ECF No. 6.) After a status conference, and after I noted the outcome of prior cases

alleging PMR, petitioner filed his amended petitioner narrowing his claim to his alleged

shoulder injury. (ECF Nos. 15, 19.) However, I additionally noted that there was a

potentially significant issue as to onset of petitioner’s alleged shoulder pain. (ECF No.

15, p. 1.)

Respondent filed his Rule 4 Report in October of 2022. (ECF No. 20.)

Respondent argued that petitioner’s medical records were inadequate to identify a

specific injury that could support a causation-in-fact analysis. (Id. at 10 (citing

Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339, 1346 (Fed. Cir.

2010)).) Assuming such analysis was appropriate, respondent further contended that

the medical records lacked a theory and medical opinion necessary to support a cause

in fact claim and that an appropriate temporal relationship was not established. (Id. at

11.) To the extent petitioner alternatively pleaded significant aggravation, respondent

contended that petitioner did not have any relevant pre-existing condition. (Id. at 12-

13.)

Following the filing of respondent’s report, petitioner filed additional medical

records (Exhibit 17), several witness affidavits (Exhibits 18-20), and an expert report by

orthopedic surgeon Uma Srikumaran, M.D. (Exhibits 21-40). (ECF No. 24.)

Respondent filed a responsive report by orthopedic surgeon Geoffrey Abrams, M.D.

(Exs. A-B; ECF No. 28.) Thereafter, I issued a Rule 5 Order confirming that the factual

question of onset of petitioner’s shoulder pain would be a central issue and advising that

a fact hearing would be necessary. (ECF No. 29.)

A video fact hearing was held on April 24, 2024. (See Transcript of Proceedings

(“Tr.”), at ECF No. 37.) Petitioner was the only witness. During the hearing, it was

revealed that petitioner had submitted a VAERS3 report. Petitioner also referenced

leave requests he submitted to his employer. Petitioner filed these materials (marked

as Exhibits 42-44) in May of 2024. (ECF No. 38.)

Thereafter, the parties proposed resolving entitlement based on written briefs.

(ECF No. 39.) Thus, petitioner filed a motion for a ruling on the written record on

August 20, 2024. (ECF No. 40.) That motion was fully briefed. (ECF Nos. 41-42.)

3 The Vaccine Adverse Reporting System (“VAERS”) is a national early warning system that is co-

managed by the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug

Administration (FDA) and was established to detect possible safety problems in U.S.-licensed vaccines.

About VAERS: Background and Public Health Important, VAERS, https://vaers.hhs.gov/about.html (last

visited Nov. 20, 2025). VAERS is a passive reporting system, meaning that it relies on individuals to

submit reports of adverse events following vaccination. Id. Anyone can submit a VAERS report. Id. As

a result, “VAERS is not designed to determine if a vaccine caused a health problem,” but it can be “useful

for detecting unusual or unexpected patterns of adverse event reporting that might indicate a possible

safety problem with a vaccine.” Id.

4

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

a. Medical Records

Petitioner received the vaccination at issue in his right shoulder on October 1,

2019. (Ex. 1, p. 1.) He had a prior history of osteoarthritis, neuropathy, bilateral thumb

joint pain, and a right shoulder dislocation in 1983. (Ex. 8, p. 102; Ex. 2, pp. 165, 177.)

About two weeks post-vaccination, on October 14, 2019, petitioner e-mailed his primary

care provider as follows:

I got my flu shot at work on 10/1 and I thought it was given a bit high on my

arm. Now for the last week, I have had deep achy pain with tingling fingers

and stiffness in the shoulder itself. It wakes me up at night and during the

day it feel like it did when I dislocated it many years ago. What do I need to

do? This is all in my right shoulder.

(Ex. 2, p. 172.) A follow up x-ray was performed the next day, on October 15, 2019. It

was negative, except for mild acromioclavicular arthrosis. (Id. at 64.)

Petitioner then presented to the emergency department for care on October 27,

2019. (Ex. 2, p. 165.) The history was as follows:

55-year-old white male ER nurse dislocated his right shoulder as a teenager

and underwent repair at that time. As he has gotten older, he has developed

some osteoarthritis for which he takes meloxicam. On 10/1 he got a flu shot

in his right shoulder. 2 days later began to notice right shoulder pain. This

became progressively worse over 2 weeks. He took a course of prednisone

which improved symptoms remarkably but these all returned as soon as he

completed with the current course of therapy. He now has progressive right

shoulder pain especially with abduction and active or passive external

rotation of the humerus. He also has some mild right neck paraspinous pain

that has full range of motion. He does note some paresthesias down his

right arm with certain motions of his shoulder, but not neck. No chills,

fevers, or other symptoms. He has noticed some increase in his bilateral

hip pain which improves with activity temporarily. chills, fevers, or sweats.

(Id.)

5

On physical exam, petitioner had full range of motion in his neck, though he had

mild tenderness on the right. (Ex. 2, p. 167.) His right shoulder was only mildly tender

to deep palpation, but he had “particularly painful” active and passive abduction and

external rotation. (Id.) The emergency department physician suspected a post

traumatic arthritis affecting petitioner’s prior shoulder dislocation; however, it was noted

that he was already on a maximum dose of meloxicam. (Id.) Accordingly, petitioner

was referred for an orthopedic surgical consult. (Id.)

He returned to the emergency department two days later, on October 30, 2019.

(Ex. 2, pp. 153-54.) At that time, he complained of one month of bilateral shoulder pain,

though mostly on the right side, along with hip and neck pain and ten days of night

sweats without fever. (Id. at 154.) On physical exam, petitioner had limited range of

motion in the right shoulder and his neck range of motion was limited by pain, but he

had normal range of motion in the hips. (Id. at 157.) Lab results were normal except for

slightly elevated erythrocyte sedimentation rate (“ESR”). (Id. at 81-84, 157-60.) The

attending physician suspected a possible reactive arthritis following vaccination. (Id. at

160.)

A follow up MRI of the neck performed the next day showed multi-level cervical

spondylosis. (Ex. 2, pp. 58-59.) An MRI of the right shoulder showed:

• Moderate/large glenohumeral joint effusion with synovitis particularly

anteriorly and within the rotator interval;

• Tendinosis of the supraspinatus and infraspinatus distal tendon fibers

with a full/near full-thickness tear of the anterior supraspinatus tendon

fibers;

• High-grade tendinosis with low-grade partial-thickness undersurface

tears of the distal tendon fibers predominantly involving the central

components of the distal subscapularis tendon;

• Marked irregularity of the glenoid labrum both anteriorly and posteriorly,

but worst anteriorly consistent with tear. There is no bone marrow

edema to suggest an acute or subacute dislocation event although

remote injury cannot be excluded by imaging;

• Tearing of the inferior glenohumeral ligament predominantly involving

the posterior band from its humeral attachment (HAGL).

(Id. at 60-63.) An MRI of the left shoulder on November 3, 2019, found moderate

acromial clavicular arthropathy with a small amount of joint fluid and abnormal signal at

the superior labrum, which might represent a tear. (Id. at 55-58.)

Petitioner then presented to an orthopedist on November 6, 2019. (Ex. 5, p. 10.)

His new patient intake form indicated that he was presenting for “30+ days of pain from

flu shot,” specifying his pain was in his bilateral shoulders and hips. (Id.) He listed the

date of injury as October 1, 2019. (Id.) During the encounter, he reported that “his pain

began to set in a couple days after his immunization and gradually progressed.” (Id. at

15.) Based on the physical exam and review of the prior MRI, the orthopedist felt

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petitioner had near to full thickness tears of the supraspinatus tendons, a subchondral

cystic formation at the humeral head, and adhesive capsulitis. (Id. at 16.) The

orthopedist agreed that the adhesive capsulitis may have been related to the

immunization, either as a direct reaction or as an exacerbation of underlying rotator cuff

pathology. (Id.) Petitioner was referred to physical therapy, which he pursued from

November 20, 2019 through January 24, 2020. (Id. at 16, 19-20; Ex. 3.) Petitioner’s

complaints of neck and hip pain were not assessed.

Petitioner subsequently presented to an immunologist on November 13, 2019, to

investigate whether he had experienced an allergic reaction to his vaccination and

reported post-vaccination symptoms affecting his right arm and both hips. (Ex. 7, pp.

10-12.) The immunologist diagnosed a probable non-IgE mediated reaction to the flu

vaccine. (Id. at 12.) However, petitioner was also referred to a neurologist for further

evaluation. (Id.) When petitioner presented to a neurologist on December 4, 2019, he

reported numbness and tingling bilaterally down his upper extremities and pain in his

bilateral lower extremities. (Ex. 4, p. 6.) On exam, he had patchy decreased sensation

to pinprick in the upper extremities and was hyperreflexic at the knees. (Id.) He was

assessed with lumbar radiculopathy, and an EMG and MRI were ordered. (Id. at 6-7.)

An MRI of the bilateral hips showed bilateral anterosuperior chondrolabral separations,

which orthopedics felt were likely early findings of osteoarthritis. (Ex. 2, pp. 55, 106.)

On December 16, 2019, petitioner presented to a rheumatologist, who diagnosed

petitioner with PMR. (Ex. 6, pp. 18-21.)

Thereafter, petitioner continued treatment for his diagnosed PMR. However, on

October 21, 2020, he returned to his orthopedist complaining that he was still

experiencing constant right shoulder pain despite the treatment for his PMR. (Ex. 11,

pp. 26, 28.) The orthopedist felt that petitioner’s adhesive capsulitis had resolved with

physical therapy, but recommended surgery to repair the rotator cuff. (Id. at 30.)

Petitioner agreed (Id.); however, after a pre-operative MRI, the radiologist felt petitioner

did not have a full-thickness rotator cuff tear, but instead moderate to severe

acromioclavicular (“AC”) joint osteoarthritis with trace fluid in the subacromial-subdeltoid

bursa. (Ex. 12, p. 20.) The orthopedist disagreed and the surgery was performed on

January 14, 2021. (Ex. 11, p. 22; Ex. 9, p. 3.) Arthroscopic findings included an intact

rotator cuff, dense subacromial bursitis, an anterior hook on the acromion, degenerative

tearing of the labrum, and grade 3 to grade 4 chondromalacia of the glenoid and of the

humeral head with extensive cartilage loss of the posterior humeral head. (Ex. 9, p. 3.)

The remainder of the medical records are not informative of the issues to be

resolved.

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b. Testimony

i. Petitioner

Petitioner filed an affidavit, dated December 8, 2021, and also testified during the

fact hearing, held on April 24, 2024. Petitioner’s affidavit focused more on his alleged

damages than on the initial onset of his symptoms. (Ex. 14.)

Although petitioner suffered a prior shoulder injury as a teenager (Tr. 8), he

testified that he was not experiencing any shoulder problems at the time of the

vaccination at issue (Id. at 9-10.) At the time of injection, however, petitioner felt

“immediate pain, [that] actually made my arm and fingers tingle and kind of hurt, which

just wasn’t normal.” (Id. at 11.) After that, petitioner, an emergency department medic

at the time, returned to work, where he found he was having difficulty reaching for the

phone at the charge nurse desk, which he discussed with the charge nurse. (Id. at 6,

12.) His arm continued to hurt at the end of his shift. (Id. at 13.) Petitioner also

recalled telling his wife about his arm pain when he got home from work. (Id. at 13-14.)

Unlike normal post-vaccination soreness, petitioner’s pain did not improve, but instead

got worse. (Id. at 13.) The achiness got “fairly aggressive” overnight and then

continued to worsen on the second day. (Id. at 15.) On the day of the vaccination, the

pain had been a “nagging, burning-type” of sensation. On the second day, however, it

became a “deep visceral ache.” (Id. at 16.)

Petitioner subsequently complained to Mr. Reid about his pain, which is

separately reflected in the affidavit discussed below. (Tr. 16.) He testified that Mr. Reid

let petitioner leave early. (Id. at 16-17.) However, the timing of this occurrence is

unclear. Petitioner testified that this interaction was “several days” into the course of his

condition (Id. at 16) and, as explained below, Mr. Reid placed this interaction in “early

October” (Ex. 20). However, petitioner confirmed in testimony that his early departure

was marked as a use of sick leave. (Tr. 16-17.) Petitioner’s subsequently filed leave

records indicate that in October of 2019, petitioner did not take sick leave until October

17 and at that time took a full 12-hour shift of leave. (Ex. 44, p. 1.) Petitioner did not

take a partial 8-hours of leave until November of 2019. (Id.)

Regarding the e-mail he sent to his primary care provider on October 14, 2019,

which had stated his shoulder had been hurting “for the last week,” petitioner testified

that this timeframe was stated “just in general” and was only an approximation. (Tr. 21-

22.) He suggested that the subject line of the e-mail (“shoulder issue 14 days after

getting flu shot”) is more representative of the fact that he had been experiencing pain

for about 14 days, ever since the time of the vaccination. (Id. at 19-21.) The pain was

getting worse throughout this period. (Id. at 22.) Petitioner testified that, around the

same time he sent this e-mail, petitioner began conducting his own research online. (Id.

at 36-37.) It was at this time that petitioner completed and submitted a VAERS report.

(Id. at 37.) Petitioner’s VAERS report was subsequently filed into the record. (Exs. 42-

43.) In the VAERS report, which was submitted October 15, 2019, petitioner described

his condition as “[e]xtreme weakness and deep aching to sharp pain. Severe sharp

8

pain when moving in some directions. Numbness to outer upper shoulder with

intermittent finger tingling. (Ex. 43, p. 2.) Contrary to petitioner’s e-mail the day prior,

the VAERs report records the date of onset as October 4, 2019, three days post

vaccination. (Id.) In his testimony, petitioner distinguished his e-mail to his primary care

provider from his VAERS report, explaining that when e-mailing his physician, he was

unaware of the SIRVA concept and was focused on pain relief. (Tr. 38.)

ii. Darlene M. Rousselle

Petitioner also filed an affidavit by his wife, Ms. Rousselle. (Ex. 18.) In pertinent

part, Ms. Rousselle averred regarding the day of petitioner’s vaccination that, “[w]hen he

came home that evening, he made mention that ‘wow this shot was the first one that

has ever really hurt. I think they may have given it too high on my arm.” (Id. at 1.)

Thereafter, she recalled that, “[o]ver the next couple days, he complained of the pain

being worse than with a normal shot.” (Id.) “By night 3, the pain was causing him to

wake up with severe pain in the right shoulder.” (Id.) “By day 4, I would say, he could

not lift his right arm past more than a quarter of the way up and he said using it to drive

was virtually impossible.” (Id.)

iii. Kayleen Martin

An additional affidavit by petitioner’s mother, Ms. Martin, was filed. (Ex. 19.) Ms.

Martin recalled that

It was the second day after he had his shot that he and his wife came to the

house to visit, and he kept rubbing his right shoulder. I asked him what was

wrong. He said that his flu shot from the day before was just really hurting

extremely bad. I could tell the pain was pretty significant because he was

just not acting himself. He said he felt that the nurse giving the shot may

have given it too high.

(Id. at 1.)

Additionally:

By the next day, my son’s wife contacted me and said that Ronnie’s

shoulder was really bad, and it was keeping him up and he was unable to

lift it over his head. That evening I went to their house to check on him and

he had less movement than he had the day prior. I asked him if it was just

the regular pain from getting a shot and he assured me that this pain was

way more than normal pain.

(Id.) Ms. Martin recalled that petitioner “missed days of work because of it for another

week or so.” (Id. at 1-2.)

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iv. Erik Reed, R.N.

Finally, Mr. Reed, petitioner’s charge nurse at his place of employment at the

time of his alleged injury, provided an affidavit recalling:

I remember one instance when Mr. Martin was working next to me at the

charge desk, and he was having issues lifting his right arm to answer the

phones. I believe this was early October of 2019. He told me he had

recently received his flu vaccine and that his arm was really hurting. I

witnessed Mr. Martin trying to push through this situation and I could see

the painful look on his face when typing on the computer and when trying

to reach for the phones. I asked him how he felt, and he stated that his arm

had this horrible deep pain and stiffness. He had stated that it was to the

point of it causing him nausea.

(Ex. 20.) Mr. Reed indicated that he released petitioner from duty that day. (Id.)

c. Expert Opinions

Petitioner filed an expert report by orthopedic surgeon Uma Srikumaran, M.D.4

(Ex. 21.) Dr. Srikumaran opined that several publications support the idea that

vaccinations can cause shoulder injuries when vaccine antigen is inadvertently injected

into the subacromial bursa, leading to a robust local immune inflammatory response

that can lead to bursitis or capsulitis and/or activate pathology affecting the biceps

tendon, glenohumeral joint. (Id. at 26-27 (citing Marko Bodor & Enoch Montalvo,

Vaccination-Related Shoulder Dysfunction, 25 VACCINE 585 (2007) (Ex. 26), S.

Atanasoff et al., Shoulder Injury Related to Vaccine Administration (SIRVA), 28 VACCINE

8049 (2010) (Ex. 23); L.H. Martín Arias et al., Risk of Bursitis and Other Injuries and

Dysfunctions of the Shoulder Following Vaccination, 35 VACCINE 4870 (2017) (Ex. 24)).)

Dr. Srikumaran noted that this process most often occurs within 48 hours of vaccination.

(Id. at 27 (citing Arias et al., supra, at Ex. 24)); however, he also cited literature finding a

three-day period of increased risk of bursitis occurring post-vaccination. (Id. at 31-32

4 Dr. Srikumaran received his medial degree from Johns Hopkins University School of Medicine in 2005,

before going on to complete an internship in general surgery and orthopedic surgery, as well as a

residency in orthopedic surgery, at Johns Hopkins Hospital in 2006 and 2010, respectively. (Ex. 22, p. 1.)

From there, Dr. Srikumaran completed a fellowship in shoulder surgery at Harvard in 2011. (Id.; Ex. 21,

p. 1.) He is board certified in orthopedic surgery, and he maintains an active medical license in Maryland.

(Ex. 22, p. 10.) Dr. Srikumaran currently works as the Director of the shoulder fellowship in the

Department of Orthopaedic Surgery and the Assistant Director of the Orthopaedic Surgery, Shoulder

Division, at Johns Hopkins University School of Medicine; the Medical Director at Howard County Johns

Hopkins Orthopaedic Surgery; and the Chair of the Department of Orthopaedic Surgery at Howard

County General Hospital. (Id. at 2.) In his clinical capacity, Dr. Srikumaran has treated approximately 10-

12 patients with shoulder dysfunction following vaccination in the last five years. (Ex. 21, p. 1.)

Additionally, Dr. Srikumaran maintains a position as an associate professor of orthopedic surgery at

Johns Hopkins University School of Medicine. (Ex. 22, p. 2.) Dr. Srikumaran has authored several

publications in the field of shoulder surgery, including two articles specifically discussing SIRVA. (Id. at 2-

6; Ex. 21, p. 1.)

10

(citing Elisabeth M. Hesse et al., Risk for Subdeltoid Bursitis After Influenza Vaccination:

A Population-Based Cohort Study, 173 ANNALS INTERNAL MED. 253 (2020) (Ex. 32)).) In

petitioner’s case, Dr. Srikumaran credits petitioner’s October 27, 2019 emergency

department record, which explicitly placed onset of petitioner’s shoulder pain at two

days post-vaccination. (Id. at 21 (citing Ex. 2, p. 165).) Dr. Srikumaran endorses the

treating orthopedist’s diagnosis of adhesive capsulitis, which he notes to be a common

sequela of SIRVA, stressing that petitioner’s positive impingement signs and reduced

range of motion are well documented. (Id. at 22.) And, although petitioner had

evidence of fraying or torn ligaments, these were asymptomatic prior to vaccination.

Thus, pursuant to his theory, the vaccine “triggered” them by initiating inflammation.

(Id.) Dr. Srikumaran therefore opines that a logical sequence of cause and effect

implicates petitioner’s vaccination as a cause of his condition. (Id. at 27.) The presence

of neck pain is not confounding, because shoulder pathology can result in pain referred

from the shoulder to the neck. (Id. at 23-24.) Dr. Srikumaran does not necessarily

accept petitioner’s PMR diagnosis as accurate but, in any event, does not believe the

right shoulder injury can be attributed to PMR, given that it had a distinct onset prior to

onset of the other symptoms later diagnosed as PMR. (Id. at 25-26.)

Respondent filed a responsive expert report by orthopedic surgeon Geoffrey

Abrams, M.D.5 (Ex. A.) Dr. Abrams stresses that, although “Dr. Srikumaran provides a

well written and referenced description of the clinical symptoms as well as mechanism

of SIRVA[,] . . . [i]n none of these referenced articles is SIRVA described as a condition

outside the shoulder.” (Id. at 8.) Dr. Abrams opines that any assessment of SIRVA is

confounded by petitioner’s broader presentation of musculoskeletal complaints,

including both cervical spine pathology and PMR. (Id. at 8-10.) Dr. Abrams notes that

petitioner repeatedly referenced experiencing bilateral shoulder pain, as well as neck

pain significant enough to warrant a spinal MRI. (Id. at 10-11.) Moreover, Dr. Abrams

opines that the onset of petitioner’s condition more likely occurred about one-week post-

vaccination, which does not support a SIRVA. (Id. at 11-12.) Dr. Abrams

acknowledges that petitioner did have significant right shoulder pathology demonstrated

on MRI, but opines that his ultimate surgical findings, including chondromalacia of the

glenoid and humerus with extensive cartilage loss of the posterior humeral head and

degenerative labrum, are not associated with SIRVA. Instead, subacromial bursitis as

would be expected in SIRVA would occur above the rotator cuff and away from the ball

and socket. (Id. at 12.)

5 Dr. Abrams received his medical degree from the University of California, San Diego, in 2007, before

going on to complete a surgical internship in the Department of General Surgery and a residency in the

Department of Orthopedic Surgery from Stanford University Hospital and Clinics in 2008 and 2012,

respectively. (Ex. B, pp. 1-2.) From there, Dr. Abrams completed a fellowship in orthopedic sports

medicine at Rush University Medical Center in 2013. (Id. at 1.) He is board certified in orthopedic

surgery with a subspecialty in orthopedic sports medicine, and he maintains an active medical license in

California. (Id. at 2.) He currently works as the Director of Sports Medicine for Varsity Athletics Lacob

Family Sports Medicine Center at Stanford University and as an associate professor at Stanford

University School of Medicine. (Id. at 1.) He has authored several peer-reviewed publications on

shoulder and other musculoskeletal pathology. (Ex. A, p. 1; Ex. B, pp. 2-31.)

11

IV. Discussion

a. Fact finding as to the onset of shoulder pain

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). 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) (concluding 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) (citing § 300aa-12(d)(3); Vaccine Rule 8),

aff’d, 746 F.3d 1334 (Fed. Cir. 2014); see also Burns, 3 F.3d at 417. 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).

“[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) (quoting the

decision below), aff’d per curiam, 968 F.2d 1126 (Fed. Cir. 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.”

12

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).

Petitioner argues that “his sworn testimony at the April 24, 2024, fact-finding

hearing, combined with medical records, as well as the supporting affidavits of

eyewitnesses, establish by a preponderance of evidence that the onset of petitioner’s

symptoms occurred within 48 hours of his October 1, 2019, flu vaccination.” (ECF No.

40, n. 4.) Petitioner argues that his October 14, 2019 e-mail to his physician (which

stated symptoms had occurred “for the last week”) should not be interpreted as

specifying that onset occurred specifically one-week prior. (Id. at pp. 14-15.) Moreover,

he notes that, at around the same time he sent this e-mail, he submitted a VAERS

report which placed onset at 3 days post-vaccination. (Id. at n. 6.) Furthermore,

petitioner’s initial in-person encounter record specifies that onset occurred 2 days post-

vaccination. (Id. at 12.) Respondent argues, however, that the evidence does not

preponderate in favor of a finding that onset occurred within 48 hours of vaccination.

(ECF No. 41, pp. 11-13.) Respondent stresses that the October 14, 2019 e-mail is the

earliest record of petitioner’s shoulder pain and is “in his own words.” (Id. at 11-12.)

Respondent further suggests that petitioner’s testimony lacks reliability, because he

testified that nurse Reed sent him home “several days” after his shoulder pain started,

but this is not supported by his leave records. (Id. at 12.) Even accounting for the

additional witness affidavits, respondent argues that petitioner’s contemporaneous

account should not be set aside in favor of later produced testimonial evidence. (Id. at

12-13.)

Several of petitioner’s arguments as to onset are unpersuasive. In particular, I

am not persuaded by petitioner’s argument that his e-mail statement that his symptoms

had been present “for the last week” can be interpreted as anything other than an

explicit statement indicative of the onset of the shoulder pain. Moreover, I agree with

respondent that it is significant that this e-mail was in petitioner’s “own words” and is the

most contemporaneous record of petitioner’s recollection. 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 the fact that 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.”).

I also do not agree with petitioner’s suggestion that the testimonial evidence is

credible enough to overcome the more contemporaneous records. As respondent

points out, it is concerning that a primary point of reference for petitioner’s recollection –

his early dismissal by nurse Reed – is not supported by his leave records. Petitioner

criticizes respondent for attempting “to discredit petitioner’s recollections by faulting him

for not being able at the fact-finding hearing to pinpoint the date on which petitioner first

13

took a sick day from work due to his worsening right shoulder pain.” (ECF No. 42, p. 2.)

However, while I am sympathetic that it is difficult to remember events that happened

years earlier, this only underscores why later testimony often fails to persuasively

contradict contemporaneous records. Among all of the affidavits and testimony, the

early dismissal was one of very few, if not the only, concrete event available to anchor

the fact witnesses accounts to a specific timeframe, and it is not ultimately corroborated.

Because I am not persuaded by petitioner’s arguments, and because I do not

find the testimonial evidence outweighs the more contemporaneous records, the only

remaining question is what conclusion can be reached from the various reports included

within the contemporaneous records. In this case, the records reflect the following:

• The earliest record was created two weeks post-vaccination, on October 14,

2019, and in it, petitioner states that, “I got my flu shot at work on 10/1 and I

thought it was given a bit high on my arm. Now for the last week, I have had

deep achy pain.” (Ex. 2, p. 172.)

• The next day, petitioner submitted a VAERS report. Petitioner identified the date

of onset of his shoulder symptoms as October 4, 2019, which is three days post-

vaccination. (Ex. 43, p. 2)

• On October 27, 2019, petitioner’s first in-person encounter for treatment at the

emergency department recorded the following history: “On 10/1 he got a flu shot

in his right shoulder. 2 days later began to notice right shoulder pain.” (Ex. 2, p.

165.)

• Two days later, on October 30, 2019, petitioner returned to the emergency

department and complained of one month of shoulder pain, which effectively

places onset at (or even right before) vaccination. (Ex. 2, pp. 153-54).

Generally, more contemporaneous histories are given greater weight. See e.g.,

R.K. v. Sec’y of Health & Human Servs., No. 03-632V, 2015 WL 10936124, at *76 (Fed.

Cl. Spec. Mstr. Sep. 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, e.g., Vergara v. Sec’y of Health &

Human Servs., No. 08-882V, 2014 WL 2795491, at *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)). However, special masters are required to consider the

record as a whole and no single record should be given outsized importance as among

medical histories taken a short time apart. Shapiro v. Sec’y of Health & Human Servs.,

101 Fed. Cl. 532, 538-59 (2011).

Here, contrary to petitioner’s later testimony, none of these records explicitly

place onset of petitioner’s shoulder pain on the date of vaccination while some explicitly

contradict the notion that onset occurred within 48 hours of vaccination. Considered as

14

a whole, these records do not demonstrate that onset of shoulder pain occurred within

48 hours of vaccination and further demonstrate a clear pattern whereby as time went

by, petitioner more closely associated his shoulder pain with his vaccination. However,

although my prior Rule 5 order cautioned that petitioner’s October 14, 2019 e-mail

stands as the most contemporaneous recollection available (ECF No. 29), petitioner’s

subsequent filing of his October 15, 2019 VAERS submission greatly complicates how

much weight can be placed on that e-mail as singularly reflecting petitioner’s earliest

accounting of his shoulder pain. Shapiro, 101 Fed. Cl. at 538 (explaining that “[l]ogic

and a few cases suggest that the special weight given an earlier record of an event over

a later one diminishes when the first record is made some time after the event recorded;

ought to diminish further when the time interval between two post hoc records is slight;

and should all but disappear where the records are both post hoc, created within a short

time of each other, and come with the same badges of reliability”).

With the filing of the VAERS report, the two most contemporaneous pieces of

evidence, both representing petitioner’s “own words” and created just a day apart, place

onset of right shoulder pain at no more than seven days post-vaccination and no fewer

than three days post vaccination. (Compare Ex. 2, p. 172, with Ex. 43, p. 2.) And,

although I am not persuaded by petitioner’s attempt to effectively rewrite the e-mail with

a years-later hindsight, I do give some credence to his testimony that the e-mail was

focused on the worsening of his pain and prompted by his pain becoming unbearable

(Tr. 28, 32), which could help explain why his e-mail incorrectly suggested a later initial

onset. Additionally, I note that the VAERS report is more consistent with the

subsequent treatment records. Thus, I find that the evidence preponderates in favor of

a finding that the initial onset of petitioner’s shoulder pain began about three days post-

vaccination and worsened thereafter.

b. Table injury

In his motion, petitioner asserts that he has satisfied the requirements of a Table

Injury of SIRVA. (ECF No. 40, pp. 8-9.) However, this argument was premised on his

assertion that he had preponderantly demonstrated that onset of his shoulder pain

occurred within 48 hours of vaccination, as required by the Vaccine Injury Table.

Because I have found that onset of shoulder pain initially occurred three days post-

vaccination, petitioner cannot demonstrate the presence of a Table SIRVA.

c. Causation-in-fact

i. Althen prong one

Under Althen prong one, petitioner must provide a “reputable medical theory,”

demonstrating that the vaccine received can cause the type of injury alleged. Pafford,

451 F.3d at 1355-56 (citations omitted). Such a theory must only be “legally probable,

not medically or scientifically certain.” Knudsen v. Sec’y of Health & Human Servs., 35

F.3d 543, 548-49 (Fed. Cir. 1994). Petitioner may satisfy the first Althen prong without

resort to medical literature, epidemiological studies, demonstration of a specific

15

mechanism, or a generally accepted medical theory. Andreu, 569 F.3d at 1378-79

(citing Capizzano v. Sec’y of Health & Human Servs., 440 F.3d 1317, 1325-26 (Fed. Cir.

2006)). However, “[a] petitioner must provide a ‘reputable medical or scientific

explanation’ for [his] theory. While it does not require medical or scientific certainty, it

must still be ‘sound and reliable.’” Boatmon v. Sec’y of Health & Human Servs., 941

F.3d 1351, 1359 (Fed. Cir. 2019) (citation omitted) (quoting Knudsen, 35 F.3d at 548-

49).

Petitioner relies on Dr. Srikumaran’s opinion, stressing that he explained, based

on published medical literature that “injection of vaccine antigen into the subacromial

bursa led to a ‘robust local immune and inflammatory response’ leading to pathology of

the subacromial space, biceps tendon, glenohumeral joint, and capsulitis.” (ECF No.

40, p. 11 (quoting Bodor & Montalvo, supra, at Ex. 26); see also Atanasoff et al., supra,

at Ex. 23.) Respondent does not dispute that this constitutes a viable theory, noting that

it is essentially the basis for the Table Injury of SIRVA (ECF No. 41, p. 17); however, he

contests that this theory is appliable to petitioner’s case, stressing both the need for

petitioners to identify a defined and recognized injury (Id. at 14-15), as well as

contending that petitioner’s case fails under Althen prongs two and three (Id. at 18-21).

In light of the above, and considering the record as a whole, petitioner has met

his preponderant burden of proof under Althen prong one.

ii. Althen prong three

The third Althen prong requires establishing a “proximate temporal relationship”

between the vaccination and the injury alleged. Althen, 418 F.3d at 1278. That term

has been equated to the phrase “medically-acceptable temporal relationship.” Id. at

1281. A petitioner must offer “preponderant proof that the onset of symptoms occurred

within a timeframe for which, given the medical understanding of the disorder’s etiology,

it is medically acceptable to infer causation-in-fact.” de Bazan v. Sec’y of Health &

Human Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008).

Of course, the Table Injury of SIRVA requires that onset of shoulder pain occur

within 48 hours of vaccination. 42 C.F.R. § 100.3(a). Given this, both parties

benchmark their arguments under Althen prong three against a 48-hour onset period,

focusing largely on the factual question of symptom onset and paying little attention to

what constitutes a timeframe from which a causal inference can be drawn. (ECF Nos.

40-42.) However, Althen prong three does not simply apply the Table timeframe.

Under Althen prong three, special masters look to the available evidence regarding the

condition’s etiology and are cautioned against setting hard and fast deadlines for onset.

Paluck v. Sec’y of Health & Human Servs., 786 F.3d 1373, 1383-84 (Fed. Cir. 2015). In

that regard, prior program experience with respect to shoulder injuries caused-in-fact by

vaccination shows that, while the medical literature generally favors a 48-hour onset in

the majority of cases, this is not absolute. Compare Pitts v. Sec’y of Health & Human

Servs., No. 18-1512V, 2023 WL 2770943, at *14 (Fed. Cl. Spec. Mstr. Apr. 4, 2023)

(finding one-week post-vaccination onset is not supported), with Murray v. Sec’y of

16

Health & Human Servs., No. 17-1357V, 2022 WL 17829797, at *16-17 (Fed. Cl. Spec.

MStr. Oct. 27, 2022) (finding entitlement where onset of shoulder pain occurred within

“a few days” and less than seven days post-vaccination), and Jewell v. Sec’y of Health

& Human Servs., No. 16-0670V, 2017 WL 7259139, at * 3 (Fed. Cl. Spec. Mstr. Aug. 4,

2017) (finding entitlement for shoulder injury occurring 72 hours post-vaccination).

In this case, for the reasons discussed in Section IV(a), supra., I have concluded

that the onset of shoulder pain arose approximately three days post-vaccination. In that

regard, while Dr. Srikumaran largely focused on a 48-hour period of onset, he also

explained that a study by Hesse et al. found an increased risk of subdeltoid bursitis

following influenza vaccination with a risk interval up to three days post-vaccination.

(Ex. 21, pp. 31-32 (discussing Hesse et al., supra, at Ex. 32).) He further explained that

“[t]he study by Hesse et al is quite informative as it relates to SIRVA as it is established

that there is an elevated risk of bursitis after getting a vaccination, more than can be

attributed to the common degenerative conditions of the shoulder (impingement,

arthritis, etc.).” (Id. at 31.) Dr. Abrams did not discuss the Hesse study or contest that it

is relevant to SIRVA. (Ex. A.) Although a specific finding of post-vaccination bursitis is

not implicated in this case, the Hesse study still serves as some evidence suggesting

that it can take up to three days to fully initiate the type of damaging local inflammatory

reaction posited by petitioner’s theory.

In light of the above, and considering the record as a whole, petitioner has met

his preponderant burden of proof under Althen prong three.

iii. Althen prong two

The second Althen prong requires preponderant proof of a logical sequence of

cause and effect, which is usually supported by facts derived from petitioner’s medical

records.6 Althen, 418 F.3d 1278; Andreu, 569 F.3d at 1375-77; Capizzano, 440 F.3d at

1326; Grant v. Sec’y of Health & Human Servs., 956 F.2d 1144, 1148 (Fed. Cir. 1992).

While the opinions of treating physicians are often favored, Capizzano, 440 F.3d at

1326, a petitioner may support a cause-in-fact claim through presentation of either

medical records or an expert medical opinion. See § 300aa-13(a).

The Federal Circuit has cautioned that the second Althen prong “is not without

meaning,” but has also indicated that satisfaction of Althen prongs one and three is

6 Medical records are generally viewed as trustworthy evidence. Cucuras v. Sec’y of Health & Human

Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993). These records are generally contemporaneous to the

medical events and “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.” Id. However, medical records and/or statements of a treating physician’s views do not per se

bind the special master. § 300aa-13(b)(1) (providing that “[a]ny such diagnosis, conclusion, judgment,

test result, report, or summary shall not be binding on the special master or court”); Snyder v. Sec’y of

Health & Human Servs., 88 Fed. Cl. 706, 745 n.67 (2009) (reasoning that “nothing . . . mandates that the

testimony of a treating physician is sacrosanct—that it must be accepted in its entirety and cannot be

rebutted”).

17

probative with respect to Althen prong two.7 Capizzano, 440 F.3d at 1326-27.

Nonetheless, temporal association alone is not enough to satisfy petitioner’s burden of

proof. See, e.g., Veryzer v. Sec’ y of Health & Hu man Servs., 100 Fed. Cl. 344, 356

(2011) (explaining that “a temporal relationship alone will not demonstrate the requisite

causal link and that petitioner must posit a medical theory causally connecting [the]

vaccine and injury”), aff’d per curiam sub nom. Veryzer v. United States, 475 F. App’x

765 (Fed. Cir. 2012); A.Y. v. Sec’y of Health & Human Servs., 152 Fed. Cl. 588, 595

(2021); Forrest v. Sec’y of Health & Human Servs., No. 10-032V, 2017 WL 4053241, at

*18 (Fed. Cl. Spec. Mstr. Aug. 10, 2017); Cozart v. Sec’y of Health & Human Servs., No.

00-590V, 2015 WL 6746616, at *18 (Fed. Cl. Spec. Mstr. Oct. 15, 2015), mot. for rev.

denied, 126 Fed. Cl. 488 (2016); Crosby v. Sec’y of Health & Human Servs., No. 08-

799V, 2012 WL 13036266, at *37 (Fed. Cl. Spec. Mstr. June 20, 2012).

Regarding the second Althen prong, petitioner argues that his own reporting of

his symptoms as associated with his vaccination helps to support a logical sequence of

cause and effect implicating the vaccine. (ECF No. 40, p. 11.) He further argues that

this causal relationship is corroborated by his treating physicians, including two

emergency department physicians who likewise associated his condition to his vaccine

on two separate occasions and an immunologist who felt his condition was an adverse

vaccine reaction. (Id. (citing Ex. 2, p. 160, 165; Ex. 7, p. 12).) But, in any event,

petitioner urges that Dr. Srikumaran’s opinion sets forth the logical sequence of cause

and effect. (Id. at 11-12 (quoting Ex. 21, p. 27).)

Aside from his concerns with respect to timing, which have otherwise been

addressed in the preceding analyses, respondent primarily argues that petitioner cannot

satisfy Althen prong two because his treating physicians disagreed as to whether his

shoulder symptoms were caused by osteoarthritis, a prior shoulder injury, his PMR, or a

degenerative disease. (ECF No. 41, p. 18 (citing Ex. 2, pp. 165, 167; Ex. 6, pp. 8, 16,

21).) Moreover, he contends that Dr. Abrams’s opinion, which stressed petitioner’s

waxing and waning course, supports the conclusion that SIRVA is a less likely

explanation for petitioner’s shoulder symptoms. (Id. at 18-19.) Additionally, respondent

argues that petitioner relies primarily on the notion of “SIRVA” without identifying a

specific diagnosis that could be analyzed under Althen. (Id. at 13-14.)

7 The Capizzano Court described the circumstances in which Althen prong two may be a stumbling block

as follows:

There may well be a circumstance where it is found that a vaccine can cause the injury at

issue and where the injury was temporally proximate to the vaccination, but it is illogical to

conclude that the injury was actually caused by the vaccine. A claimant could satisfy the

first and third prongs without satisfying the second prong when medical records and

medical opinions do not suggest that the vaccine caused the injury, or where the probability

of coincidence or another cause prevents the claimant from proving the vaccine caused

the injury by preponderant evidence.

440 F.3d at 1327.

18

I am not persuaded by respondent’s arguments. As petitioner noted, Dr.

Srikumaran’s report explains that a logical sequence of cause and effect is

demonstrated where the vaccine causes an inflammatory reaction that can lead to

bursitis, tendinitis, capsulitis, and activation of previously asymptomatic chronic

shoulder pathology.8 (Ex. 21, p. 27.) In that regard, although petitioner undoubtedly

had a complicated overall medical history inclusive of other musculoskeletal and/or

rheumatologic complaints, his medical encounters reflect that he had an acute onset of

new right shoulder pain following his vaccination (e.g., Ex. 2, p. 165), whereas other

complaints were not reported until later (Id. at 154), contemporaneous MRI evidence

showing distinct pathology (including a glenohumeral joint effusion) affecting the right

but not left shoulder (compare id. at 62-63, with id. at 57-58), and his treating

orthopedist diagnosed, inter alia, a vaccine-related adhesive capsulitis (Ex. 5, p. 16).

Moreover, petitioner’s later medical records reflect that, even after petitioner’s PMR was

well established, the orthopedist still felt that petitioner had a shoulder injury additional

to that PMR, which ultimately required surgery. (Ex. 11, pp. 26, 30.) And, even after he

began complaining of bilateral shoulder pain, petitioner still indicated that the right

shoulder was more painful. (Ex. 2, p. 154.) Although Dr. Abrams was concerned that

petitioner’s course changed over time, the medical records reflect that the adhesive

capsulitis component of petitioner’s shoulder condition was felt to have resolved with

physical therapy (Ex. 11, p. 30), potentially contributing (along with ongoing steroid

treatment for PMR) to the seemingly fluctuating course of petitioner’s symptoms. Dr.

Abrams’s opinion that petitioner’s glenohumeral joint effusion as demonstrated on his

initial right shoulder MRI is per se incompatible with SIRVA (Ex. A, p. 12) is not nuanced

enough to overcome all of foregoing without more. Accord Pulsipher v. Sec’y of Health

& Human Servs., No. 21-2133V, 2025 WL 1364203, at *12-14 (Fed. Cl. Spec. Mstr. Apr.

24, 2025) (accepting Dr. Abrams’s opinion that subacromial bursitis would be unlikely to

activate osteoarthritis in the glenohumeral joint, but explaining that the SIRVA medical

literature does support some instances of glenohumeral involvement), mot. for rev.

denied, No. 21-2133, slip op. (Fed. Cl. Sep. 3, 2025).

d. Factor unrelated to vaccination

Once petitioner has met his own prima facie burden of proof, respondent may still

demonstrate by a preponderance of evidence that the injury was nonetheless caused by

a factor unrelated to the vaccination. § 300aa-13(a)(1)(B). However, although

respondent argued that petitioner’s complicated medical history should complicate his

own prima facie showing, he did not argue that any other cause of petitioner’s condition

is preponderantly supported. (ECF No. 41.) Nor did Dr. Abrams suggest on

respondent’s behalf that any specific alternative cause could be supported.

8 Petitioner’s medical records reflect that he did have a remote prior shoulder injury (Ex. 2, p. 165), and

Dr. Srikumaran’s theory did also encompass the idea that the vaccine may trigger pre-existing pathology

(Ex. 21, p. 27). Accordingly, seemingly out of an abundance of caution, petitioner alternatively argued

that he could demonstrate a significant aggravation. (ECF No. 40, pp. 16-18.) However, respondent

affirmatively argued that a significant aggravation analysis is not appropriate because “petitioner has not

established a pre-existing right shoulder condition.” (ECF No. 41, pp. 21-22.) Thus, it is not necessary to

address significant aggravation.

19

Dr. Abrams opined that “a single cohesive diagnosis of a rheumatological

condition is more plausible than arguing that disparate sites of musculoskeletal pain are

due to a variety of unrelated medical condition which all happened to occur at the same

time – which is unlikely.” (Ex. A, p. 12.) However, he did not identify what, if any,

condition would explain petitioner’s condition and further stressed that “[i]t should be

noted that I am not an expert in rheumatology.” (Id.) Although Dr. Abrams did

otherwise discuss petitioner’s PMR diagnosis, he was careful to couch his opinion only

as reflecting the unlikelihood that petitioner’s condition could be explained as SIRVA

and never explicitly endorsed PMR as a more likely than not explanation of petitioner’s

complete clinical presentation. (Id. at 10-11.)

V. Conclusion

After weighing the evidence, and considering the record as a whole, I find that

petitioner has preponderantly demonstrated that he is entitled to compensation for a

right shoulder injury caused-in-fact by his October 1, 2019 flu vaccination. A separate

damages order will be issued

IT IS SO ORDERED.

s/Daniel T. Horner

Daniel T. Horner

Special Master

20