VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_19-vv-00002
Package ID: USCOURTS-cofc-1_19-vv-00002
Petitioner: Cecilia Ortiz
Filed: 2019-01-02
Decided: 2024-02-23
Vaccine: Tdap
Vaccination date: 2016-01-20
Condition: left shoulder injury related to vaccine administration (SIRVA)
Outcome: compensated
Award amount USD: 161200

AI-assisted case summary:
Cecilia Ortiz filed a petition for compensation under the National Vaccine Injury Compensation Program alleging that she suffered a left shoulder injury related to vaccine administration (SIRVA) as a result of a tetanus, diphtheria, and acellular pertussis (Tdap) vaccine administered on January 20, 2016. She further alleged that her injuries lasted for more than six months. Initially, the respondent contested entitlement, arguing that the onset of her shoulder pain was not within 48 hours of vaccination. However, after a ruling on entitlement found that her shoulder pain likely began within the 48-hour timeframe for a Table claim, the respondent amended their position. In an amended Rule 4(c) report, the respondent conceded that Ms. Ortiz was entitled to compensation, agreeing that she met the criteria for a Table SIRVA injury, including no prior shoulder issues, onset within 48 hours, pain limited to the injection site, no other identified condition, and residual effects lasting more than six months. Based on this concession and the evidence, the court found Ms. Ortiz entitled to compensation. Subsequently, a decision awarding damages was issued. The parties agreed to a proffer of compensation, and the court awarded Ms. Ortiz a total of $161,200.00. This amount included $81,500.00 for pain and suffering and $79,700.00 for past unreimbursable expenses, which were paid jointly to Ms. Ortiz and various medical providers including Avant Surgery Center, LLC, Dacoma Anesthesia, Magna Surgery Center, and Veritas Pain Management.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_19-vv-00002-0
Date issued/filed: 2022-08-04
Pages: 10
Docket text: PUBLIC ORDER/RULING (Originally filed: 06/30/2022) regarding 39 Findings of Fact & Conclusions of Law,, Scheduling Order,, Order on Motion for Ruling on the Record, Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
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Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 1 of 10
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 19-0002V
UNPUBLISHED
CECILIA ORTIZ, Chief Special Master Corcoran
Petitioner, Filed: June 30, 2022
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Findings of Fact; Onset; Tdap
HUMAN SERVICES, Vaccine; Shoulder Injury Related to
Vaccine Administration (SIRVA)
Respondent.
Amy A. Senerth, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Sarah Christina Duncan, U.S. Department of Justice, Washington, DC, for Respondent.
FINDINGS OF FACT1
On January 2, 2019, Cecilia Ortiz filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleged that she suffered a shoulder injury related to vaccine
administration (“SIRVA”) as a result of a tetanus, diphtheria, and pertussis vaccine
(“Tdap”) administered to her left shoulder on January 20, 2016. Petition at 1. The case
was assigned to the Special Processing Unit of the Office of Special Masters.
1 Because this unpublished fact ruling contains a reasoned explanation for the action in this case, I am
required to post it on the United States Court of Federal Claims' website in accordance with the E-
Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic
Government Services). This means the fact ruling 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 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 2 of 10
After review of the record and other filings, and for the reasons discussed below, I
find that Petitioner’s left shoulder pain likely began within the 48-hour timeframe for the
Table claim.
I. Relevant Procedural History
Ms. Ortiz filed her petition for compensation along with medical record exhibits
from January to March 2019. (ECF No. 1). Ten months later, Respondent filed a status
report stating that he did not believe engaging in settlement discussions was appropriate
and proposed filing his Rule 4(c) Report. (ECF No. 28).
On January 6, 2020, Respondent filed his Rule 4 (c) Report contesting entitlement
in this case. (ECF No. 29). Specifically, Respondent argued that Petitioner’s Table SIRVA
claim failed because she had not established that the onset of her shoulder pain began
within 48 hours after receiving her Tdap vaccination on January 20, 2016. Respondent’s
Report at 7-8. In support, Respondent noted that five days after vaccination, Petitioner
presented to the office of her primary care physician, but did not report any shoulder pain
or vaccine related complaints. Id.; citing Ex. 2 at 34-35.3 Thereafter, Petitioner did not
report shoulder pain to any medical provider for nearly five months, despite her claim that
she was wearing a sling and taking Motrin daily. Id. at 8.
The parties subsequently filed briefing requesting a ruling on onset. My ruling is
set forth below.
II. Issue
The issue presented for resolution is whether the onset of Petitioner’s left shoulder
pain occurred within 48 hours after vaccination, as required by the Vaccine Injury Table.
42 C.F.R. §§ 100.3(a) XIV.B. (2017) (Tdap vaccination) and 100.3(c)(10).
III. Authority
Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act
§ 11(c)(1). A special master must consider, but is not bound by, any diagnosis,
conclusion, judgment, test result, report, or summary concerning the nature, causation,
and aggravation of petitioner’s injury or illness that is contained in a medical record.
§ 13(b)(1). “Medical records, in general, warrant consideration as trustworthy evidence.
3 Respondent also argued that Petitioner has not established that she suffered a non-Table injury because
there is insufficient evidence that the vaccine administration caused her to suffer a left shoulder injury and
because she has not filed an expert report supporting her claim. Id. at 8.
2

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 3 of 10
The 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).
Accordingly, 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 *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this rule
does not always apply. In Lowrie, the special master wrote that “written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Lowrie, at *19.
The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Human Servs., 42 Fed.
Cl. 381, 391 (1998). The Court later outlined four possible explanations for
inconsistencies between contemporaneously created medical records and later
testimony: (1) a person’s failure to recount to the medical professional everything that
happened during the relevant time period; (2) the medical professional’s failure to
document everything reported to her or him; (3) a person’s faulty recollection of the events
when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did
not exist. La Londe v. Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013),
aff’d, 746 F.3d 1335 (Fed. Cir. 2014).
The Court has also said that medical records may be outweighed by testimony that
is given later in time that is “consistent, clear, cogent, and compelling.” Camery, 42 Fed.
Cl. at 391 (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-2808, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998). However, the Federal Circuit recently
“reject[ed] as incorrect the presumption that medical records are accurate and complete
as to all the patient’s physical conditions.” Kirby v. Sec’y of Health & Hum. Servs., 997
F.3d 1378, 1383 (Fed. Cir. 2021). The credibility of the individual offering such testimony
must also be determined. 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).
A special master may find that the first symptom or manifestation of onset of an
injury occurred “within the time period described in the Vaccine Injury Table even though
the occurrence of such symptom or manifestation was not recorded or was incorrectly
recorded as having occurred outside such period.” § 13(b)(2). “Such a finding may be
made only upon demonstration by a preponderance of the evidence that the onset [of the
3

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 4 of 10
injury] . . . did in fact occur within the time period described in the Vaccine Injury Table.”
Id.
The special master is obligated to fully consider and compare the medical records,
testimony, and all other “relevant and reliable evidence contained in the record.” La
Londe, 110 Fed. Cl. at 204 (citing § 12(d)(3); Vaccine Rule 8); see also 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 medical
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).
IV. Findings of Fact
I make the following findings after a complete review of the record to include all
medical records, affidavits, Respondent’s Rule 4(c) Report, and any additional evidence
filed. Specifically, I observe as follows:
 Ms. Ortiz received a Tdap vaccine in her left deltoid on January 20, 2016. Ex. 1
at 3-4. She was 50 years-old at the time.
 Ms. Ortiz’s medical history includes a pulmonary embolism in 1991,
hypertension, hyperlipidemia, obesity, and allergic rhinitis. Ex. 2 at 39-45; Ex. 7
at 34-45. There is no indication in the records of any previous left shoulder
injuries.
 On January 25, 2016, five days after vaccination, Petitioner presented to her
primary care physician (“PCP”) complaining of feeling sluggish and eating more
than usual, possibly in relation to her blood pressure medications. Ex. 2 at 34-38.
There is no mention of any shoulder complaints during this visit.
 On June 14, 2016, nearly five months after vaccination, Ms. Ortiz presented to
her Nurse Practitioner Bettina Raju (“NP Raju”) at her PCP’s office complaining
of “left shoulder pain off an[d] on x6 months. States January had Tdap
vaccination in left deltoid and noticed pain occurring after injection. Most pain
occurs when twisting arm to put on bra with occasional numbness and tingling to
extremity when in same position for extended periods of time. Denies trauma or
injury. Has tried various OTC analgesics with minimal improvement and tried hot
stone massage which helped for some time. Participating in yoga exercises.” Ex.
2 at 30. On examination, Petitioner’s left shoulder was tender to palpation and
she had a reduced range of motion, although the nerve impingement test was
negative. Id. at 31. NP Raju noted that Petitioner’s left shoulder pain radiated into
4

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 5 of 10
her neck and arm. Id. Ms. Ortiz was assessed with left shoulder bursitis and
prescribed home physical therapy. She was also instructed to ice the area and
perform range of motion and stretching exercises. Id.
 On September 1, 2016, Petitioner returned to NP Raju complaining that her
shoulder pain had not improved with massage therapy, acupuncture and
massages. Ex. 2 at 26. Instead, her pain was worsening and radiating to the
lower arm. Id. This time after examination, NP Raju, with Dr. Nicastro, noted that
Ms. Ortiz was experiencing “moderate-severe spasms, moderate-severe
tenderness and moderate-severe decreased range of motion.” Id. at 27. An MRI
of the left upper arm was ordered. Id. at 28.
 Ms. Ortiz underwent an MRI of her left shoulder on September 2, 2016. Ex. 2 at
51. The clinical history states “No trauma. Very sharp stabbing sensation from
left shoulder joint down to hand. Pain started Jan. 2016.” The impression was
“Distal supraspinatus tendinopathy” and “hypertrophic changes of the
acromioclavicular joint with evidence of impingement.” Id.
 On September 8, 2016, Ms. Ortiz returned to NP Raju to review the results of her
MRI. Ex. 2 at 21-23. Ms. Ortiz reported that the pain medication was helping her
a little, but she was concerned because she was going out of the country on a
backpacking trip and worried that her shoulder pain might worsen. Id. The
Apley’s Scratch Test (to measure reduced range of motion) was “[p]ositive for
tendonitis of the rotator cuff.” Id. at 22. NP Raju noted “moderate-severe spasms,
moderate-severe tenderness and moderate decreased range of motion” and
assessed “bicipital tendinitis, left shoulder.” Id. Ms. Ortiz was referred to pain
management. Id. She was prescribed Tramadol for pain. Ex. 2 at 23.
 On September 14, 2016, Ms. Ortiz underwent a left shoulder injection under
ultrasound guidance, left cervical paraspinals, trapezius, and rhomboid trigger
point injections, and a limited ultrasound evaluation of the left shoulder bursa. Ex.
8 at 2. During the evaluation, mild edema was noted in the subdeltoid bursa. Id.
at 3.
 On October 10, 2016, Petitioner presented to Nurse Practitioner Kenneth Fuller
with complaints of “persistent pain on left arm and shoulder.” Ex. 2 at 16. The
Apley’s Scratch Test was again “[p]ositive for tendonitis of the rotator cuff.” Id. He
placed a therapy treatment order for “ice, electrical muscle stimulation,
ultrasound, manipulation, physical medicine and myofascial release.” Id. at 17-
18.
5

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 6 of 10
 On October 12, 2016, Ms. Ortiz underwent a second left steroid injection with
ultrasound guidance, left cervical paraspinals, trapezius, and rhomboid trigger
point injections, and a limited ultrasound evaluation of the left shoulder bursa. Ex.
8 at 6. The same finding of edema as previously noted was stated in the report.
Id. at 7.
 On October 24, 2016, Ms. Ortiz presented to Dr. Lacrecia Foster reporting that
she had been seen by pain management and received three steroid injections.
Ex. 2 at 10. Petitioner reported that she experienced some improvement but that
she recently went on a backpacking trip and re-flared her shoulder. Id. at 10. She
declined repeat injections and had put her arm in a sling to alleviate the pain. Id.
Ms. Ortiz requested a physical therapy referral as the pain had been waking her
up at night. Id. Dr. Foster also prescribed a muscle relaxant and Tramadol. Id. at
13.
 On November 18, 2016, Petitioner underwent an arthrogram of her left shoulder
which showed “moderate tendinosis … involving the supraspinatus and
infraspinatus tendon with a shallow low-grade partial thickness articular sided
tear involving the anterior fibers of the infraspinatus tendon… 2. Partial thickness
interstitial tear is noted involving the mid fibers of the subscapularis tendon… 3.
Moderate degenerative changes are noted involving the posterosuperior labrum
without a definite labral tear … 4. Moderate to severe arthrosis … involving the
acromio clavicular joint with synovial and capsular hypertrophy. Near total
effacement of the fat overlying myotendinous junction of the supraspinatus mild
increasing anatomic risk for impingement.” Ex. 11 at 2-3. She received an intra-
articular injection of lidocaine in her left shoulder. Ex. 11 at 1.
 On December 22, 2016, Ms. Ortiz underwent surgery – a left shoulder
arthroscopy, manipulation under anesthesia and lysis of adhesions. Ex. 4 at 3.
The postoperative diagnosis was left shoulder adhesive capsulitis and left
shoulder partial thickness supraspinatus tendon tear. Id. at 4. The operative
report notes that when the subacromial space was visualized during surgery,
“there was extensive synovitis and bursitis present within the subacromial
space.” Id. at 5. A complete bursectomy was performed. Id.
 On April 12, 2017, Ms. Ortiz returned to Dr. Foster, for a follow up and treatment
of “left shoulder pain, cervical pain radiating to left shoulder, arm, and thoracic
pain.” Ex. 2 at 6. On examination, Dr. Foster noted that Petitioner was positive for
cervical spine joint and nerve root injury on the left as well as for a supraspinatus
injury on the left. Id. at 8. Dr. Foster ordered electrical muscle stimulation,
ultrasound, physical medicine and myofascial release, three times per week for
two weeks. Petitioner was instructed to return in two weeks. Id.
6

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 7 of 10
 The last mention of the left shoulder is during an examination on May 4, 2017,
where it is noted that “bursitis of the left shoulder – stable.” Ex. 7 at 8.
 In an undated letter, Claudia Bonacchi from Cla’-Bo Specialty Day Spa, stated
that she provided massage services to Ms. Ortiz about 7 times between June
2017 and September 2018. Ex. 5. Ms. Bonacchi stated that during Petitioner’s
last session in September 2018, Ms. Ortiz “complained of acute pain under the
shoulder blade and at the base of the neck.” Id.
 No records have been filed for any treatment after December 27, 2018. Ex. 7 at
3.
 Ms. Ortiz filed an affidavit to explain the circumstances she recalled surrounding
her receipt of the Tdap vaccine and to explain her delay in seeking medical
treatment for her shoulder. Ex. 12 at 1. She stated that on January 20, 2016, “I
was sitting down, and the vaccine administrator was standing. I thought it was a
little high up my arm towards my shoulder compared to flu shots I received in the
past. Immediately following receipt of the Tdap vaccine, I felt pain in my left
shoulder… but I figured it was normal after a shot so I did not tell anyone.” Ms.
Ortiz stated that she delayed seeking treatment because she “did not think I
needed a doctor until the pain was interfering with my sleep and at work the pain
was there all day.” She stated that she did not mention the shoulder pain at her
January 25, 2016 visit because “I assumed I was just sore, and didn’t think much
of it at the time.” Ms. Ortiz stated that she did not return to be seen for shoulder
pain “because I typically am one to avoid doctors. Instead, I took over the counter
pain medication, used essential oils, and used a sling and other supports
because my elbow, wrist and hand hurt from the radiating pain.” Id. at 2, ¶7. It
was only during an incident where her cousin bumped her arm and the pain was
so severe that “it took my breath away for a few minutes,” that Ms. Ortiz decided
that she needed to seek medical care.
V. Ruling Regarding Onset
After a careful review of the record, I find that the evidence preponderates (albeit
barely) in Petitioner’s favor on the disputed onset issue.
There is no dispute that Ms. Ortiz did not suffer from any left shoulder symptoms
prior to receiving the Tdap vaccine in January 2016. And the record corroborates the fact
of subsequent injury – even though, admittedly, there are no close-in-time treatment
records. It is true that the one close-in-time record (from when Petitioner saw her
physician within a week of receiving the vaccine) does not memorialize a report of pain.
But this is not inconsistent with what other Program petitioners experience, based on the
7

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 8 of 10
assumption that their pain is likely transitory. Indeed, many SIRVA cases feature medical
record notations from physicians recommending that a patient wait a period of time after
vaccination to allow time for the shoulder pain to fade before seeking treatment.
Subsequent records in this case, however, all corroborate the injury and onset, and the
Vaccine Act expressly does not obligate claimants to prove onset issues with evidence
from within the alleged timeframe in any event. Section 13(b)(2).
The sworn testimony of Petitioner on the onset question is also credible and in
agreement with the contemporaneously created treatment records. I do not agree with
Respondent’s argument that Ms. Ortiz’s two affidavits are inconsistent and that the
“contemporaneous medical records conflicts with petitioner’s recollection.” Respondent’s
Brief at 8. The fact that Ms. Ortiz first averred that she felt pain immediately after
vaccination does not necessarily conflict with the statement in her second affidavit where
she states that the vaccine area was “sore” and “little by little, the soreness became pain.”
Pain threshold is a subjective perception. Soreness may be perceived as pain by some
individuals, but not by others. In any event, Respondent’s argument on this point is weak
and unpersuasive.
Another factor that weighs in favor of a finding of 48-hour onset of left shoulder
pain is the absence of any statement or record that places the onset of Ms. Ortiz’s left
shoulder pain outside the 48-hour window. By contrast, there are at least two records
where Ms. Ortiz reports that her pain began on the day of vaccination. See e.g., Ex. 2 at
30-33 (regarding pain in her arm “L shoulder pain off/on x 6 months. States in January
had Tdap vaccination in L deltoid and noticed pain occurring after injection.”); Ex. 2 at 51
(“sharp stabbing sensation from L shoulder joint down to hand. Pain started Jan 2016”).
Unquestionably, the five-month records gap from vaccination to the first efforts to
treat Ms. Ortiz’s alleged shoulder pain undermines Petitioner’s case. As Respondent
argues, it is reasonable to expect that the average Program claimant might seek medical
treatment sooner if in fact the person was experiencing sudden post-vaccination pain.
However, as noted above, claimants may often misperceive the extent of their shoulder
injury, or downplay its significance, leading them to delay treatment. See, e.g., Williams
v. Sec’y of Health & Human Servs., No. 17-830V, 2019 WL 1040410, at *9 (Fed. Cl. Spec.
Mstr. Jan. 31, 2019) (noting a delay in seeking treatment for five-and-a-half months
because petitioner underestimated the severity of her shoulder injury); Tenneson v. Sec’y
of Health & Human Servs., No. 16-1664V, 2018 WL 3083140, at *5 (Fed. Cl. Spec. Mstr.
March 30, 2018), review denied, 142 Fed. Cl. 329 (2019) (finding a 48-hour onset of
shoulder pain despite a nearly six-month delay in seeking treatment); Marino v. Sec’y of
Health & Human Servs., No. 16-622V, 2018 WL 2224736, at *2 (Fed. Cl. Spec. Mstr. Mar.
26, 2018) (noting a delay in seeking treatment for several months due to petitioner’s work
schedule and difficulty making appointments); Knauss v. Sec’y of Health & Human Servs.,
8

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 9 of 10
No. 16-1372V, 2018 WL 3432906 (Fed. Cl. Spec. Mstr. May 23, 2018) (noting a three-
month delay in seeking treatment).
Here, as in other cases, Respondent argues that a special master cannot rely on
the statements of the petitioner alone regarding a key element like onset. See e.g., Juno
v. Sec’y of Health & Human Servs., No. 18-643, 2021 WL 4782691, at * 5 (Fed. Cl. Spec.
Mstr. Sept. 13, 2021). But the Federal Circuit has expressly recognized that witness
testimony on issues pertaining to fact matters can be proven by reliance on testimonial
evidence (even if the evidence must be weighed against the records themselves, which
continue to have evidentiary significance). Kirby, 997 F.3d at 1383. Respondent has not
identified any inconsistencies or discrepancies in the medical records. And in this case,
the relevant witness statements are not the only evidence in favor of an onset finding
consistent with a Table SIRVA claim.
At bottom, the evidence preponderates, although weakly, in favor of a
determination that onset began in 48 hours of vaccination. Of course, the fact of
Petitioner’s delay will bear on any damages to be awarded in this case, since it either
underscores a SIRVA mild enough to be tolerated for a long time, or establishes
Petitioner’s own contributions to severity.4 But these considerations are separate from
whether onset did happen as Petitioner alleges.
VI. Scheduling Order
Given my findings of fact regarding onset of Ms. Ortiz’s left shoulder pain,
Respondent should evaluate and provide his current position regarding the merits of
Petitioner’s case.
Accordingly, the following is ORDERED:
(1) By Monday, August 5, 2022, Petitioner shall file all updated medical
records.
4 This appears to be a classic example of an individual holding off on medical treatment for what started as
mild shoulder pain, but progressed and worsened to a severe condition – thereby exacerbating the
condition. Guarding or non-use of the shoulder can lead to adhesive capsulitis or frozen shoulder, and
Petitioner’s non-use may have also led to neck and shoulder pain because she began shifting the use of
her left arm to other parts of the body. The backpacking trip she took in October 2016 also likely exacerbated
her pain and symptoms. Due to the lack of care early on, what may have otherwise been a mild shoulder
injury progressed to a serious injury requiring surgical intervention.
9

Case 1:19-vv-00002-UNJ Document 40 Filed 08/04/22 Page 10 of 10
(2) Respondent shall file, by no later than Monday, August 29, 2022, an
amended Rule 4(c) Report reflecting Respondent’s position in light of the
above fact-finding.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
10

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DOCUMENT 2: USCOURTS-cofc-1_19-vv-00002-1
Date issued/filed: 2022-09-29
Pages: 2
Docket text: PUBLIC ORDER/RULING (Originally filed: 08/29/2022) regarding 44 Ruling on Entitlement. Signed by Chief Special Master Brian H. Corcoran. (kle) Service on parties made.
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Case 1:19-vv-00002-UNJ Document 46 Filed 09/29/22 Page 1 of 2
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 19-0002V
UNPUBLISHED
CECILIA ORTIZ, Chief Special Master Corcoran
Petitioner, Filed: August 29, 2022
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Ruling on Entitlement; Concession;
HUMAN SERVICES, Table Injury; Tetanus Diphtheria
acellular Pertussis (Tdap) Vaccine;
Respondent. Shoulder Injury Related to Vaccine
Administration (SIRVA)
Amy A. Senerth, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Martin Conway Galvin, U.S. Department of Justice, Washington, DC, for Respondent.
RULING ON ENTITLEMENT1
On January 2, 2019, Cecilia Ortiz filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that she suffered a left shoulder injury related to vaccine
administration (“SIRVA”) as a result of a tetanus, diphtheria, and acellular pertussis
(“Tdap”) vaccine administered on January 20, 2016. Petition at 1. Petitioner further
alleges that her injuries lasted for more than six months. Petition at 4. The case was
assigned to the Special Processing Unit of the Office of Special Masters.
On January 6, 2020, Respondent filed his Rule 4(c) report recommending that
compensation be denied, arguing that the onset of Petitioner’s shoulder pain was not
1 Because this unpublished Ruling contains a reasoned explanation for the action in this case, I am required
to post it on the United States Court of Federal Claims' website in accordance with the E-Government Act
of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling 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 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:19-vv-00002-UNJ Document 46 Filed 09/29/22 Page 2 of 2
within 48 hours of vaccination. ECF No. 29. After the parties briefed the issue, I issued a
ruling finding that Petitioner’s shoulder pain likely began with the 48-hour timeframe for a
Table claim. ECF No. 39 at 2.
On August 29, 2022, Respondent filed an Amended Rule 4(c) report in which he
states that he does not contest that Petitioner is entitled to compensation in this case.
Respondent’s Rule 4(c) Report at 1. Specifically, Respondent states that “[b[ased on the
Chief Special Maser’s fact ruling, and the evidence submitted in this case, DICP will not
continue to contest that petitioner suffered SIRVA as defined by the Vaccine Injury Table.”
Id. at 7-8. Respondent further agrees that:
[P]etitioner had no recent history of pain, inflammation, or dysfunction of her
left shoulder; the onset of pain occurred within 48 hours after receipt of an
intramuscular vaccination; the pain was limited to the shoulder in which the
vaccine was administered; and, no other condition or abnormality, such as
brachial neuritis, has been identified to explain petitioner’s left shoulder
pain. 42 C.F.R. §§ 100.3(a), (c)(10). In addition, petitioner suffered the
residual effects of her condition for more than six months. 42 U.S.C. §
300aa-11(c)(1)(D)(i). Therefore, based on the record as it now stands and
subject to his right to appeal the Findings of Fact, respondent does not
dispute that petitioner has satisfied all legal prerequisites for compensation
under the Act.
Id. at 8.
In view of Respondent’s position and the evidence of record, I find that
Petitioner is entitled to compensation.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
2

================================================================================
DOCUMENT 3: USCOURTS-cofc-1_19-vv-00002-2
Date issued/filed: 2024-02-23
Pages: 8
Docket text: PUBLIC DECISION (Originally filed: 01/22/2024) regarding 71 DECISION Stipulation/Proffer, Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
--------------------------------------------------------------------------------
Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 1 of 8
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 19-0002V
CECILIA DE LEON,
Chief Special Master Corcoran
Petitioner,
v.
Filed: January 22, 2024
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Amy A. Senerth, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Sarah Christina Duncan, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION AWARDING DAMAGES1
On January 2, 2019, Cecilia de Leon filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that she suffered a left shoulder injury related to vaccine
administration (“SIRVA”) as a result of a tetanus, diphtheria, and acellular pertussis
(“Tdap”) vaccine administered to her on January 20, 2016. Petition at 1. The case was
assigned to the Special Processing Unit of the Office of Special Masters.
On August 29, 2022, a ruling on entitlement was issued finding Petitioner entitled
to compensation. On January 19, 2024, Respondent filed a proffer on award of
compensation (“Proffer”) indicating Petitioner should be awarded the following:
1 Because this Decision 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 Decision 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 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2018).

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 2 of 8
A. Pain and Suffering: $81,500.00, to Petitioner in actual pain and suffering.
B. Past Unreimbursable Expenses to Petitioner and Avant Surgery Center, LLC:
Respondent proffers that Petitioner should be awarded past unreimbursable
expenses in the amount of $28,482.60 for services provided by Avant Surgery
Center, LLC.
C. Past Unreimbursable Expenses to Petitioner and Dacoma Anesthesia
Respondent proffers that Petitioner should be awarded past unreimbursable
expenses in the amount of $4,118.00 for services provided by Dacoma
Anesthesia.
D. Past Unreimbursable Expenses to Petitioner and Magna Surgery Center:
Respondent proffers that Petitioner should be awarded past unreimbursable
expenses in the amount of $25,317.87 for services provided by Magna Surgery
Center.
E. Past Unreimbursable Expenses to Petitioner and Veritas Pain Management:
Respondent proffers that Petitioner should be awarded past unreimbursable
expenses in the amount of $11,783.94 for services provided by Veritas Pain
Management.
Proffer at 1-3. In the Proffer, Respondent represented that Petitioner agrees with the
proffered award. Id. Based on the record as a whole, I find that Petitioner is entitled to an
award as stated in the Proffer.
Pursuant to the terms stated in the attached Proffer, I award Petitioner the
following:
A. A lump sum payment of $81,500.00, in the form of a check payable to
Petitioner;
B. A lump sum payment of $28,482.60, in the form of check made payable jointly
to Petitioner, Cecilia de Leon and Avant Surgery Center, LLC;
C. A lump sum payment of $4,118.00, in the form of a check made payable
jointly to Petitioner, Cecilia de Leon and Dacoma Anesthesia;
D. A lump sum payment of $25,317.87, in the form of a check made payable
jointly to Petitioner, Cecilia de Leon and Magna Surgery Center, and
E. A lump sum payment of $11,783.94, in the form of a check made payable
jointly to Petitioner, Cecilia de Leon and Veritas Pain Management;
2

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 3 of 8
These amounts represent compensation for all damages that would be available
under Section 15(a). The Clerk of Court is directed to enter judgment in accordance with
this decision.3
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
3 Pursuant to Vaccine Rule 11(a), entry of judgment can be expedited by the parties’ joint filing of notice
renouncing the right to seek review.
3

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 4 of 8
IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
)
CECILIA DE LEON, )
)
Petitioner, )
) No. 19-2V
v. ) Chief Special Master Corcoran
) ECF
SECRETARY OF HEALTH AND HUMAN )
SERVICES, )
)
Respondent. )
)
RESPONDENT’S PROFFER ON AWARD OF COMPENSATION
On January 2, 2019, Cecilia de Leon (“petitioner”) filed a petition under the National
Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to -34 (“Vaccine Act” or “Act”).
Petitioner alleged that she suffered a left shoulder injury related to vaccine administration
(“SIRVA”) as a result of a tetanus, diphtheria, and acellular pertussis (“Tdap”) vaccine
administered on January 20, 2016. Petition at 1.
On January 6, 2020, respondent filed his Rule 4(c) Report, recommending that entitlement
to compensation be denied and that the petition be dismissed because petitioner’s onset of left
shoulder pain was not clearly within 48 hours of vaccination. ECF No. 29. On March 30, 2021,
the Chief Special Master ordered petitioner to file a motion for a fact ruling. ECF No. 35. On
June 28, 2021, petitioner filed a motion for a ruling on the record. ECF No. 37. Respondent
filed a response on July 28, 2021. ECF No. 38. On June 30, 2022, the Chief Special Master
found “that Petitioner’s left shoulder pain likely began within the 48-hour timeframe for the
Table claim.” Findings of Fact, ECF No. 39 at 2, 9.

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 5 of 8
On August 29, 2022, respondent filed an Amended Vaccine Rule 4(c) Report advising
that, in light of Chief Special Master Corcoran’s factual finding that the onset of symptoms took
place within 48 hours is the law of the case and the medical evidence submitted in this case,
respondent did not dispute that petitioner had satisfied all legal prerequisites for compensation
under the Vaccine Act. ECF No. 42 at 2, 7-8. The same day, Chief Special Master Corcoran
entered a Ruling on Entitlement, finding petitioner entitled to Vaccine Act compensation for her
Table SIRVA injury. ECF No. 44. Respondent now proffers that petitioner receive an award as
follows:
I. Items of Compensation
A. Pain and Suffering
Respondent now proffers that, based on the Chief Special Master’s entitlement decision
and the evidence of record, Cecilia de Leon should be awarded $81,500.00 in actual pain and
suffering. See 42 U.S.C. § 300aa-15(a)(4). Petitioner agrees.
B. Past Unreimbursable Expenses to Petitioner and Avant Surgery Center, LLC
Evidence supplied by petitioner documents outstanding charges for services provided by
Avant Surgery Center, LLC related to her vaccine-related injury. Respondent proffers that
petitioner should be awarded past unreimbursable expenses in the amount of $28,482.60 for
services provided by Avant Surgery Center, LLC. Petitioner agrees.
C. Past Unreimbursable Expenses to Petitioner and Dacoma Anesthesia
Evidence supplied by petitioner documents outstanding charges for services provided by
Dacoma Anesthesia related to her vaccine-related injury. Respondent proffers that petitioner
should be awarded past unreimbursable expenses in the amount of $4,118.00 for services
provided by Dacoma Anesthesia. Petitioner agrees.
2

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 6 of 8
D. Past Unreimbursable Expenses to Petitioner and Magna Surgery Center
Evidence supplied by petitioner documents outstanding charges for services provided by
Magna Surgery Center related to her vaccine-related injury. Respondent proffers that petitioner
should be awarded past unreimbursable expenses in the amount of $25,317.87 for services
provided by Magna Surgery Center. Petitioner agrees.
E. Past Unreimbursable Expenses to Petitioner and Veritas Pain Management
Evidence supplied by petitioner documents outstanding charges for services provided by
Veritas Pain Management related to her vaccine-related injury. Respondent proffers that
petitioner should be awarded past unreimbursable expenses in the amount of $11,783.94 for
services provided by Veritas Pain Management. Petitioner agrees.1
II. Form of the Award
Petitioner is a competent adult. Evidence of guardianship is not required in this case.
Respondent recommends that the compensation provided to Cecilia de Leon should be made
through lump sum payments as described below and requests that the Chief Special Master’s
decision and the Court’s judgment award the following2:
A. A lump sum payment of $81,500.00, representing compensation for pain and
suffering, in the form of a check payable to petitioner, Cecilia de Leon.
1 The parties have no objection to the amount of the proffered award of damages. Assuming the
Chief Special Master issues a damages decision in conformity with this proffer, the parties waive
their right to seek review of such damages decision. However, respondent reserves his right,
pursuant to 42 U.S.C. § 300aa-12(e), to seek review of the Chief Special Master’s August 29,
2022 entitlement ruling and underlying factual findings issued on June 30, 2022.
2 Should petitioner die prior to entry of judgment, the parties reserve the right to move the Court
for appropriate relief. In particular, respondent would oppose any award for future medical
expenses, future pain and suffering, and future lost wages.
3

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 7 of 8
B. A lump sum payment of $28,482.60, representing compensation for
unreimbursable medical expenses for services provided by Avant Surgery Center, LLC, in the
form of a check jointly payable to petitioner, Cecilia de Leon, and Avant Surgery Center, LLC.
Petitioner agrees to endorse this payment to Avant Surgery Center, LLC, and forward the check
to P.O. Box 20029, Sugar Land, TX 77496.
C. A lump sum payment of $4,118.00, representing compensation for
unreimbursable medical expenses for services rendered by Dacoma Anesthesia, in the form of a
check jointly payable to petitioner, Cecilia de Leon, and Dacoma Anesthesia. Petitioner agrees
to endorse this payment to Dacoma Anesthesia, and forward the check to P.O. Box 17179, Sugar
Land, TX 77496.
D. A lump sum payment of $25,317.87, representing compensation for
unreimbursable medical expenses for services provided by Magna Surgery Center, in the form of
a check jointly payable to petitioner, Cecilia de Leon, and Magna Surgery Center. Petitioner
agrees to endorse this payment to Magna Surgery Center, and forward the check to 3726 Dacoma
Street, Houston, TX 77092.
E. A lump sum payment of $11,783.94, representing compensation for
unreimbursable medical expenses for services provided by Veritas Pain Management, in the
form of a check jointly payable to petitioner, Cecilia de Leon, and Veritas Pain Management.
Petitioner agrees to endorse this payment to Veritas Pain Management, and forward the check to
P.O. Box 17479, Sugar Land, TX 77496.
III. Summary of Recommended Payments Following Judgment
A. Lump Sum paid to petitioner, Cecilia de Leon: $81,500.00
B. Lump Sum paid jointly to petitioner, Cecilia de Leon, and
Avant Surgery Center, LLC: $28,482.60
4

Case 1:19-vv-00002-UNJ Document 76 Filed 02/23/24 Page 8 of 8
C. Lump Sum paid jointly to petitioner, Cecilia de Leon, and
Dacoma Anesthesia: $4,118.00
D. Lump Sum paid jointly to petitioner, Cecilia de Leon, and
Magna Surgery Center: $25,317.87
E. Lump Sum paid jointly to petitioner, Cecilia de Leon, and
Veritas Pain Management: $11,783.94
Respectfully submitted,
BRIAN M. BOYNTON
Principal Deputy Assistant Attorney General
C. SALVATORE D’ALESSIO
Director
Torts Branch, Civil Division
HEATHER L. PEARLMAN
Deputy Director
Torts Branch, Civil Division
LARA A. ENGLUND
Assistant Director
Torts Branch, Civil Division
s/ Sarah C. Duncan
SARAH C. DUNCAN
Trial Attorney
Torts Branch, Civil Division
U.S. Department of Justice
P.O. Box 146
Benjamin Franklin Station
Washington, D.C. 20044-0146
Tel: (202) 514-9729
Email: sarah.c.duncan@usdoj.gov
DATED: January 19, 2024
5