VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_20-vv-00211
Package ID: USCOURTS-cofc-1_20-vv-00211
Petitioner: Trina Lower
Filed: 2020-02-26
Decided: 2024-04-08
Vaccine: influenza
Vaccination date: 2017-11-18
Condition: shoulder injury related to vaccine administration (SIRVA)
Outcome: compensated
Award amount USD: 81618

AI-assisted case summary:
Trina Lower filed a petition for compensation under the National Vaccine Injury Compensation Program, alleging that she suffered a shoulder injury related to vaccine administration (SIRVA) caused by an influenza vaccine administered on November 18, 2017. The case was assigned to the Special Processing Unit of the Office of Special Masters. After settlement efforts failed, Petitioner was ordered to file a motion for a ruling on the record, which she did on August 15, 2022. Respondent filed a response on December 1, 2022. The Chief Special Master issued a ruling on entitlement on December 8, 2023, finding that Petitioner is entitled to compensation for a Table SIRVA. The ruling noted that Petitioner first reported left shoulder pain to her primary care physician approximately three weeks after the vaccination, associating the pain with the vaccine. Medical records showed ongoing pain, reduced range of motion, and several cortisone injections. The court found that Petitioner met the criteria for a Table SIRVA, including no prior history of shoulder problems, onset of pain within 48 hours of vaccination (though the medical records were vague, the court found preponderant evidence of onset within the timeframe), pain limited to the left shoulder, and no other condition explaining the symptoms. Respondent did not dispute most of these criteria. On April 8, 2024, a decision awarding damages was issued. Respondent filed a proffer on award of compensation, indicating Petitioner should be awarded $81,618.31, comprised of $80,000.00 for pain and suffering and $1,618.31 for out-of-pocket expenses. Petitioner agreed with the proffered award. The court awarded Petitioner a lump sum payment of $81,618.31.

Theory of causation field:
Table

Public staged source text:

================================================================================
DOCUMENT 1: USCOURTS-cofc-1_20-vv-00211-0
Date issued/filed: 2024-01-12
Pages: 7
Docket text: PUBLIC ORDER/RULING (Originally filed: 12/08/2023) regarding 61 Ruling on Entitlement, Order on Motion for Ruling on the Record. Signed by Chief Special Master Brian H. Corcoran. (kle) Service on parties made.
--------------------------------------------------------------------------------
Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 1 of 7
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-211V
UNPUBLISHED
TRINA LOWER, Chief Special Master Corcoran
Petitioner, Filed: December 8, 2023
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Entitlement to Compensation; Ruling
HUMAN SERVICES, on the Record; Findings of Fact;
Influenza (“Flu”); Shoulder Injury
Respondent. Related to Vaccine Administration
(SIRVA);
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Debra A. Filteau Begley, U.S. Department of Justice, Washington, DC, for Respondent.
RULING ON ENTITLEMENT1
On February 26, 2020, Trina Lower 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 shoulder injury related to vaccine
administration (“SIRVA”) caused by an influenza (“flu”) vaccine administered on
November 18, 2017. Petition at 1. The case was assigned to the Special Processing Unit
of the Office of Special Masters. For the reasons set forth below, I find that Petitioner is
entitled to compensation.
1 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 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 2 of 7
I. Relevant Procedural History
During the claim’s life, some effort was made at settlement, but the parties could
not find agreement. Accordingly, Petitioner was ordered to file a motion for a ruling on the
record, doing so on August 15, 2022. Motion for Ruling on the Record (“Mot.”), ECF No.
56. Respondent filed a response on December 1, 2022. Respondent’s Rule 4(c) Report
and Response to Petitioner’s Motion for a Ruling on the Record (“Opp.”), ECF No. 60.
The matter is ripe for resolution.
II. Petitioner’s Medical Records
Petitioner received a flu vaccine in her left shoulder on November 18, 2017, at her
place of employment. Ex. 1 at 1. A little over three weeks later, she reported left shoulder
pain to her primary care physician, Dr. Steven Tekippe, on December 11, 2018. Ex. 3 at
15. She associated the pain with the vaccination, and an examination revealed reduced
range of motion. Id. A cortisone injection was administered. Id.
On January 24, 2018, Petitioner returned to Dr. Tekippe, now reporting that she
was pursuing a workers’ compensation claim due to her left shoulder injury “stemming
from” the November 18 flu vaccine. Ex. 3 at 13. She also reported that the steroid injection
helped, but her pain was returning. A second steroid injection was administered. Id.
Petitioner next sought care on April 27, 2018, informing Dr. Tekippe that she had
experienced “moderate improvement” since the last steroid injection, but still was feeling
some pain. Ex. 3 at 11. She was assessed with bursitis, and a third injection was
administered. Id. at 11.
On June 27, 2018, Petitioner returned to Dr. Tekippe with reports of ongoing left
shoulder pain she attributed to a flu vaccine. Ex. 3 at 8. She also reported right shoulder
pain that could be the result of compensating for the left shoulder injury. Id. She was
diagnosed with arthralgia of the left shoulder region and pain in the left shoulder. Id.
Petitioner had an MRI on June 28, 2018, which showed impingement and minimal
tendinopathy. Ex. 17 at 53.
Petitioner began occupational therapy on December 18, 2018. Ex. 17 at 29. At the
initial meeting, Petitioner reported that her symptoms “started after she received a flu shot
last year in the left shoulder.” Id. Further, she stated that cortisone injections gave her
“about 2 to 3 months” of relief. Id. She attended eleven sessions and was discharged on
February 1, 2019, after making “excellent gains”. Id. at 28, 43.
2

Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 3 of 7
On May 3, 2019, Petitioner returned to Dr. Tekippe with complaints of left shoulder
pain she attributed to “an injury…stemming from an injection for influenza.” Ex. 3 at 6.
She was assessed with bursitis and received another cortisone injection. Id. at 6-7. On
November 20, 2019, Petitioner again complained of shoulder pain “related to previous
injection for flu immunization” and received another steroid injection. Ex. 6 at 9.
Petitioner submitted an affidavit in support of her claim. Ex. 7. Therein, she states
that she received a flu vaccine on October 26, 2018, and suffered the residual effects of
her injury for mor than six months.
III. Fact Findings and Ruling on Entitlement
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
Section 11(c)(1). In addition to requirements concerning the vaccination received, the
duration and severity of petitioner’s injury, and the lack of other award or settlement,3 a
petitioner must establish that she suffered an injury meeting the Table criteria, in which
case causation is presumed, or an injury shown to be caused-in-fact by the vaccination
she received. Section 11(c)(1)(C).
The most recent version of the Table, which can be found at 42 C.F.R. § 100.3,
identifies the vaccines covered under the Program, the corresponding injuries, and the
time period in which the particular injuries must occur after vaccination. Section 14(a).
Pursuant to the Vaccine Injury Table, a SIRVA is compensable if it manifests within 48
hours of the administration of an influenza vaccine. 42 C.F.R. § 100.3(a)(XIV)(B). A
vaccine recipient shall be considered to have suffered SIRVA if such recipient manifests
all of the following:
(i) No history of pain, inflammation or dysfunction of the affected shoulder
prior to intramuscular vaccine administration that would explain the alleged
signs, symptoms, examination findings, and/or diagnostic studies occurring
after vaccine injection;
(ii) Pain occurs within the specified time frame;
3 In summary, a petitioner must establish that she received a vaccine covered by the Program, administered
either in the United States and its territories or in another geographical area but qualifying for a limited
exception; suffered the residual effects of her injury for more than six months, died from her injury, or
underwent a surgical intervention during an inpatient hospitalization; and has not filed a civil suit or collected
an award or settlement for her injury. See § 11(c)(1)(A)(B)(D)(E).
3

Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 4 of 7
(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).
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. Section
13(b)(1). “Medical records, in general, warrant consideration as trustworthy evidence.
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 & Hum. 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 & Hum. Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, the
Federal Circuit has recently “reject[ed] as incorrect the presumption that medical records
are always accurate and complete as to all of the patient’s physical conditions.” Kirby v.
Sec'y of Health & Hum. Servs., 997 F.3d 1378, 1383 (Fed. Cir. 2021). Medical
professionals may not “accurately record everything” that they observe or may “record
only a fraction of all that occurs.” Id.
Medical records may be outweighed by testimony that is given later in time that is
“consistent, clear, cogent, and compelling.” Camery v. Sec’y of Health & Hum. Servs., 42
Fed. Cl. 381, 391 (1998) (citing Blutstein v. Sec’y of Health & Hum. Servs., No. 90-2808,
1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998). The credibility of the
individual offering such testimony must also be determined. Andreu v. Sec’y of Health &
Hum. Servs., 569 F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Hum.
Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).
A. Factual Findings Regarding a Table SIRVA
After a review of the entire record, I find that a preponderance of the evidence
demonstrates that Petitioner has satisfied the QAI requirements for a Table SIRVA.
4

Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 5 of 7
1. Petitioner Had No Prior Left Shoulder Condition or Injury that
would Explain her Symptoms
The first requirement for a Table SIRVA is a lack of problems associated with the
affected shoulder prior to vaccination that would explain the symptoms experienced after
vaccination. 42 C.F.R. § 100.3(c)(10)(i). Respondent does not dispute that Petitioner
meets this criterion, and I find that she has demonstrated a lack of history of pain,
inflammation, or dysfunction of her left shoulder that would explain her symptoms.
2. Onset of Petitioner’s Injury Occurred within Forty-Eight Hours of
her Vaccination
The medical records preponderantly establish onset of injury close-in-time to
vaccination. Petitioner first reported shoulder pain twenty-three days after her November
18, 2018, vaccination, and associated her shoulder pain with the earlier vaccination. Ex.
3 at 15. Thereafter, Petitioner continued to link her shoulder pain temporally to the flu
vaccine. See Ex. 3 at 13 (record from January 24, 2018, stating that Petitioner’s shoulder
injury “stem[ed] from” the flu vaccination); Ex. 3 at 8 (record from June 27, 2018, reporting
ongoing shoulder pain Petitioner attributed to the flu vaccine); Ex. 17 at 29 (record from
December 18, 2018, stating that Petitioner’s symptoms “started after she received a flu
shot last year in the left shoulder”).
Respondent argues that Petitioner’s statements are vague, failing to identify a
specific onset date for her shoulder symptoms. Opp. at 6-7. Even so, a finding of Table-
consistent onset can be made based on such a record. Program petitioners are not
required to marshal records setting forth with chronographic specificity the precise day
and hour that their onset manifested. As noted above, Petitioner consistently linked her
shoulder pain to the November 18, 2018, flu vaccine – whereas there are no records
suggesting an onset outside of 48-hours post-vaccination.
Further, the relevant medical records show that Petitioner reported shoulder pain
in a relatively timely manner in comparison to the date of vaccination Thus, Petitioner first
began to complain of shoulder pain within approximately three weeks of the vaccine, and
did not attribute her pain to any other injury or cause. It is common for SIRVA petitioners
to delay seeking treatment, thinking the injury will resolve on its own, especially since
patients are often told by medical providers at the time of vaccination to expect some
soreness and pain for a period of time after. And individuals also often misconstrue the
nature of their injury, and therefore fail to inform treaters of all specific facts relevant to
onset until later. Here, the added detail of onset did not “wait” for months before being
5

Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 6 of 7
provided, but began to be reported in a reasonable time post-vaccination. And Petitioner
affirmatively and repeatedly linked her shoulder pain to the flu vaccine.
Accordingly, there is preponderant evidence that establishes the onset of
Petitioner’s left shoulder pain more likely than not occurred within 48-hours of vaccination.
3. Petitioner’s Pain was Limited to her Left Shoulder
Respondent does not contest this aspect of Petitioner’s claim, and there is nothing
in the records to suggest otherwise.
4. There is No Evidence of Another Condition or Abnormality
The last criteria for a Table SIRVA state that there must be no other condition or
abnormality which would explain a petitioner’s current symptoms. 42 C.F.R. §
100.3(c)(10)(iv). Respondent does not contest this aspect of Petitioner’s claim, and there
is nothing in the records to suggest that any such condition or abnormality exists.
B. Other Requirements for Entitlement
In addition to establishing a Table injury, a petitioner must also provide
preponderant evidence of the additional requirements of Section 11(c). Respondent does
not dispute that Petitioner has satisfied these requirements in this case, and the overall
record contains preponderant evidence to fulfill these additional requirements.
The record shows that Petitioner received a flu vaccine intramuscularly on
November 18, 2018, in the United States. Ex. 1 at 1; see Section 11(c)(1)(A) (requiring
receipt of a covered vaccine); Section 11(c)(1)(B)(i)(I) (requiring administration within the
United States or its territories). There is no evidence that Petitioner has collected a civil
award for her injury. Ex. 7; Section 11(c)(1)(E) (lack of prior civil award).
Based upon all of the above, Petitioner has established that she suffered a Table
SIRVA. Additionally, she has satisfied all other requirements for compensation. I therefore
find that Petitioner is entitled to compensation in this case.
Conclusion
In view of the evidence of record, I find that there is preponderant evidence
that Petitioner satisfies the QAI requirements for a Table SIRVA. Further, based on
the evidence of record, I find that Petitioner is entitled to compensation.
6

Case 1:20-vv-00211-UNJ Document 64 Filed 01/12/24 Page 7 of 7
Accordingly, the parties shall file a Joint Status Report by January 4, 2024,
indicating whether a brief attempt at settlement discussions would be productive.
IT IS SO ORDERED.
/s/ Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
7

================================================================================
DOCUMENT 2: USCOURTS-cofc-1_20-vv-00211-1
Date issued/filed: 2024-04-08
Pages: 5
Docket text: PUBLIC DECISION (Originally filed: 03/01/2024) regarding 67 DECISION Stipulation/Proffer Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
--------------------------------------------------------------------------------
Case 1:20-vv-00211-UNJ Document 68 Filed 04/08/24 Page 1 of 5
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-211V
TRINA LOWER, Chief Special Master Corcoran
Petitioner, Filed: March 1, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Debra A. Filteau Begley, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION AWARDING DAMAGES1
On February 26, 2020, Trina Lower 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 shoulder injury related to vaccine
administration (“SIRVA”) as a result of an influenza vaccine administered on November
18, 2017. Petition at 1. The case was assigned to the Special Processing Unit of the
Office of Special Masters.
On December 8, 2023, a ruling on entitlement was issued, finding Petitioner
entitled to compensation for a SIRVA. On February 26, 2024, Respondent filed a proffer
on award of compensation (“Proffer”) indicating Petitioner should be awarded $81,618.31
(comprised of $80,000.00 for pain and suffering and $1,618.31 for out-of-pocket
expenses). Proffer at 2. In the Proffer, Respondent represented that Petitioner agrees
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 1:20-vv-00211-UNJ Document 68 Filed 04/08/24 Page 2 of 5
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 a lump
sum payment of $81,618.31 (comprised of $80,000.00 for pain and suffering and
$1,618.31 for out-of-pocket expenses) in the form of a check payable to Petitioner.
This amount represents 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.
2

Case 1:20-vv-00211-UNJ Document 68 Filed 04/08/24 Page 3 of 5
IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
__________________________________________
)
TRINA LOWER, )
)
Petitioner, )
) No. 20-211V (ECF)
v. ) Chief Special Master Corcoran
)
SECRETARY OF HEALTH )
AND HUMAN SERVICES, )
)
Respondent. )
RESPONDENT’S PROFFER ON AWARD OF COMPENSATION
On February 26, 2020, Trina Lower (“petitioner”) filed a petition for compensation under
the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to 34 (“Vaccine Act”
or “Act”), alleging that she suffered a shoulder injury related to vaccine administration
(“SIRVA”), as defined in the Vaccine Injury Table, following administration of an influenza
vaccine on November 18, 2017. ECF # 1 (Petition). On December 1, 2022, the Secretary of
Health and Human Services (“respondent”) filed a combined Vaccine Rule 4(c) Report
recommending against compensation and Response to Petitioner’s Motion for a Ruling on the
Record.1 ECF # 60. One year later, on December 8, 2023, Chief Special Master Corcoran issued
a Ruling on Entitlement which included a factual finding that petitioner’s shoulder pain began
within 48 hours of her November 18, 2017 vaccination. ECF # 61. Based on that factual
finding, and respondent’s acknowledgement that all other requirements for a Table SIRVA claim
1 Respondent explained that petitioner’s most contemporaneous medical records contain only
vague references to onset and do not specifically put the onset of her shoulder pain within the 48-
hour Vaccine Table timeframe for SIRVA, and recommended that petitioner’s request for a
ruling on the record be denied. Other than onset, respondent agreed that all other SIRVA
requirements were met. See ECF # 60; 42 C.F.R. § 100.3(c)(10).

Case 1:20-vv-00211-UNJ Document 68 Filed 04/08/24 Page 4 of 5
were met, the Chief Special Master concluded that petitioner was entitled to compensation for a
Table SIRVA claim.2 See id.
I. Items of Compensation
Based on the evidence of record, respondent proffers that petitioner should be awarded a
total of $81,618.31, for all damages, which includes $80,000.00 representative of pain and
suffering, and $1,618.31 representative of out-of-pocket medical and related expenses. These
amounts represent all elements of compensation to which petitioner would be entitled under 42
U.S.C. § 300aa-15(a). Petitioner agrees.
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 petitioner should be made through a
lump sum payment as described below, and requests that the Chief Special Master’s damages
decision and the Court’s judgment award the following: a lump sum payment of $81,618.31 in
the form of a check payable to petitioner.3 Petitioner agrees.
Respectfully submitted,
BRIAN M. BOYNTON
Principal Deputy Assistant Attorney General
C. SALVATORE D’ALESSIO
Director
Torts Branch, Civil Division
2 Respondent has no objection to the amount of the proffered award of damages set forth herein.
Assuming the Chief Special Master issues a damages decision in conformity with this proffer,
respondent waives his 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 December 8, 2023, entitlement decision.
3 Should petitioner die prior to the entry of judgment, respondent would oppose any award for
future medical expenses, future pain and suffering, and future lost wages, and the parties reserve
the right to move the Court for appropriate relief.

Case 1:20-vv-00211-UNJ Document 68 Filed 04/08/24 Page 5 of 5
HEATHER L. PEARLMAN
Deputy Director
Torts Branch, Civil Division
DARRYL R. WISHARD
Assistant Director
Torts Branch, Civil Division
S/ DEBRA A. FILTEAU BEGLEY
DEBRA A. FILTEAU BEGLEY
Senior 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)616-4181
Dated: February 26, 2024 Debra.Begley@usdoj.gov