VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_20-vv-01340
Package ID: USCOURTS-cofc-1_20-vv-01340
Petitioner: Teresa Mazza
Filed: 2020-10-07
Decided: 2025-11-05
Vaccine: influenza
Vaccination date: 2018-10-11
Condition: right shoulder bursitis and shoulder dysfunction
Outcome: compensated
Award amount USD: 115373.33

AI-assisted case summary:
On October 7, 2020, Teresa Mazza filed a petition alleging that an influenza vaccination administered in her right arm on October 11, 2018 caused a shoulder injury. Her Table SIRVA claim was dismissed after a findings-of-fact ruling because the record did not support onset within 48 hours. She continued on a causation-in-fact theory.

The records described right-shoulder problems before and after vaccination. Before the flu shot, she had reported right-sided pain in January 2018. After vaccination, the contemporaneous records did not document immediate shoulder pain. The later litigation focused on whether the vaccine could still be linked to bursitis and right-shoulder dysfunction despite delayed documented onset. Respondent opposed entitlement. Special Master Daniel T. Horner found that the Table claim failed but that the evidence supported an off-Table injury caused by vaccination.

On September 10, 2025, Special Master Horner granted entitlement on the off-Table theory. Respondent then proffered damages, and Ms. Mazza accepted. On November 5, 2025, she was awarded $115,373.33, consisting of $110,000.00 for pain and suffering and $5,373.33 for past unreimbursable expenses. The public record reviewed for this update does not show future lost earnings or annuity compensation.

Theory of causation field:
Adult petitioner; influenza vaccine October 11, 2018; right shoulder bursitis/dysfunction. COMPENSATED after Table SIRVA failed but off-Table causation was granted. Table claim failed because onset within 48 hours was not shown; documented onset was delayed. SM Daniel T. Horner nevertheless found off-Table vaccine causation for right shoulder bursitis/dysfunction. Petition filed October 7, 2020; fact ruling August 10, 2023; entitlement September 10, 2025; damages November 5, 2025. Award $115,373.33 = $110,000.00 pain/suffering + $5,373.33 past unreimbursable expenses.

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_20-vv-01340-0
Date issued/filed: 2023-09-11
Pages: 9
Docket text: PUBLIC ORDER/RULING (Originally filed: 08/10/2023) regarding 37 Findings of Fact & Conclusions of Law, Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
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Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 1 of 9
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1340V
TERESA MAZZA, Chief Special Master Corcoran
Petitioner,
v. Filed: August 10, 2023
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Ryan D. Pyles, U.S. Department of Justice, Washington, DC, for Respondent.
FINDINGS OF FACT AND CONCLUSIONS OF LAW DISMISSING TABLE CLAIM1
On October 7, 2020, Teresa Mazza 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”) due to an influenza (“flu”) vaccine received on October 11, 2018.
See Petition. The case was assigned to the Special Processing Unit (“SPU”) of the Office
of Special Masters.
1 Because this Fact Ruling 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 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 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 2 of 9
For the reasons discussed below, the record does not preponderantly support the
conclusion that Petitioner’s shoulder pain began within 48 hours post-vaccination –
thereby requiring dismissal of her Table claim. This leaves a potential causation-in-fact
claim, however – and some final efforts at settlement might be advisable before the case
is transferred from SPU.
I. Relevant Procedural History
The petition was accompanied by the affidavit and medical records required by the
Vaccine Act. Exs. 1-8, filed October 7, 2020 (ECF No. 1); see Section 11(c).3 In alleging
that her symptoms began within forty-eight (48) hours after vaccination, the petition cited
to the earliest medical records. Petition at Preamble; ¶¶ 4-5 (citing Ex. 2 at 33-35). Her
affidavit does not address onset, however. Ex.8.
Approximately 15 months after the case was activated, Respondent completed his
medical review and entered into settlement discussions. Status Report filed November 8,
2021 (ECF No. 24); see also Status Report filed May 11, 2021 (ECF No. 18) (indicating
Petitioner’s earlier conveyance of a demand). Six months later, however, the parties
reached an impasse. Status Report filed May 16, 2022 (ECF No. 29).
On June 14, 2022, Respondent filed his report pursuant to Vaccine Rule 4(c),
which sets forth his opposition to compensation of the alleged Table SIRVA claim – in
part, because Respondent avers, that Petitioner has not established the requisite onset
of symptoms within 48 hours after vaccination. Rule 4(c) Report (ECF No. 30).
On September 7, 2022, Petitioner timely filed her Brief in Support of Entitlement
(“Brief”) (ECF No. 32). She did not avail herself of the opportunity to file any additional
evidence, however. On October 19, 2022, Respondent filed his Response (ECF No. 33),
which was followed on November 3, 2022, by Petitioner’s Reply (ECF No. 34). The matter
is now ripe for adjudication.
II. Applicable Legal Standards
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). 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.
3 See also updated medical records filed on November 12, 2020, as Exs. 9-10 (ECF No. 11), and on June
9, 2021, as Ex. 11 (ECF No. 20).
2

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 3 of 9
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, this rule
does not always apply. “Written records which are, themselves, inconsistent, should be
accorded less deference than those which are internally consistent.” Murphy v. Sec’y of
Health & Hum. Servs., No. 90-882V, 1991 WL 74931, *4 (Fed. Cl. Spec. Mstr. April 25,
1991), quoted with approval in decision denying review, 23 Cl. Ct. 726, 733 (1991), aff'd
per curiam, 968 F.2d 1226 (Fed.Cir.1992)). And 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 United States Court of Federal Claims has 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 & Hum. 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 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 fact 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 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.” Section 13(b)(2). “Such a finding may
3

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 4 of 9
be made only upon demonstration by a preponderance of the evidence that the onset [of
the 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 Section 12(d)(3); Vaccine Rule 8); see also Burns v.
Sec’y of Health & Hum. 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).
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) (2017).
The criteria establishing a SIRVA under the accompanying Qualifications and Aids to
Interpretation (“QAI”) are as follows:
Shoulder injury related to vaccine administration (SIRVA). 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 (even if the condition causing the neurological
abnormality is not known). A vaccine recipient shall be considered to have
suffered SIRVA if such recipient manifests all of the following:
(i) No history of pain, inflammation or dysfunction of the affected shoulder
prior to intramuscular vaccine administration that would explain the alleged
signs, symptoms, examination findings, and/or diagnostic studies occurring
after vaccine injection;
(ii) Pain occurs within the specified time frame;
(iii) Pain and reduced range of motion are limited to the shoulder in which
the intramuscular vaccine was administered; and
4

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 5 of 9
(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).
III. Findings of Fact
I make the following findings based on a complete review of the record to include
all medical records, affidavits, additional evidence, and arguments by the parties. The
following points are particularly relevant:
• Petitioner has received primary care at East Ridge Family Medicine in Rochester,
New York, since at least 2014. Ex. 2 at 75-77. Her medical history included
depression and anxiety. Id. Following a motor vehicle accident in or before 2009,
she had chronic pain primarily in her lower back. See, e.g., id. at 70-74 (reflecting
MRI findings of lumbar spondylosis and degenerative disc disease).
• In January 2018, Petitioner sought care twice for acute neck pain, assessed as
either a musculoskeletal injury or nerve impingement and treated with Flexeril and
non-steroidal anti-inflammatory drugs (“NSAIDs”). Ex. 2 at 40-45.4
• In May 2018, Petitioner complained of a several-week history of right elbow/
forearm pain, which was assessed as lateral epicondylitis, and treated with rest
and conservative measures. Ex. 2 at 39-40. This was not addressed at the next
encounter on August 24, 2018. Id. at 35-37.
• On October 11, 2018, Petitioner received the subject vaccine in her right arm. Ex.
1 at 2.5
4 At the first encounter for this complaint, on January 19, 2018, Petitioner reported “a one-week hx right-
sided neck pain.” Ex. 2 at 44-45. This is most contemporaneous, specific, and likely to be accurate with
regard to the onset of neck pain – notwithstanding the second relevant encounter, which provides that it
“started on 1/11/2017.” Id. at 42 (emphasis added).
5 While the primary care provider has supplied a certified immunization summary (and neither the fact of
vaccination or its site is in controversy), it is unclear where the vaccination actually occurred (i.e. the location
of its administration). See generally Ex. 2 (not reflecting an encounter for the vaccination date); id. at 35
(indicating that the primary care provider recorded the fact of the vaccination afterwards, at her first
encounter for right shoulder pain); but see id. at 31 (subsequent record with Petitioner’s report of receiving
vaccination “in this office”).
5

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 6 of 9
• The next medical record is signed by Marc Lavender, M.D., after an in-person
encounter on Monday, October 22, 2018. Ex. 2 at 33-34.
o It provides: “Writer spoke to patient over weekend for symptoms suspicious
for neuropathic pain into right arm and hand following flu shot a week prior
(see note below).” Id. at 33 (emphasis added).
o The “note below” reads: “10/20/18 Telephone call note: 3 days after flu
shot was given on 10/11/18 in her dominant right arm (usually has in left
arm), developed pain at injection site with intermittent radiation to her wrist.
Has dropped things due to sharp pains. Office recommended Tylenol and
heat – no help. No shortness of breath, no rash.” Ex. 2 at 33.
o On October 22, 2018, Dr. Lavender recorded that Petitioner’s pain was no
longer going to the right hand, only to the right elbow. Ex. 2 at 33. On exam,
the right arm had normal range of motion, but “notable reproducible right
lateral upper arm pain” and right deltoid tenderness. Id. at 34. Dr. Lavender
assessed that the pain was “likely related to localized inflammation triggered
by the immunization, with possible stimulation of adjacent nervous system
structures resulting in pain.” Id. Petitioner refused gabapentin (for fear of
addiction), ibuprofen (for fear of stomach irritation), and Tylenol (as
ineffective); she would start with conservative measures. Id.
• Next, on October 30, 2018, Erin Lineman, M.D., recorded Petitioner’s report that
after the October 11th vaccination, “her right arm felt fine, but the next morning
she woke up and it was very sore. The following day, she felt like she ‘could
not move’ her right arm at all.” Ex. 2 at 31. Petitioner was “quite stressed” about
the pain and potential that the vaccine was “given wrong.” Id. Dr. Lineman provided
home exercises, recommended continuation of ibuprofen, and prescribed
gabapentin for additional pain relief. Ex. 2 at 31.6
• On October 31, 2018, Petitioner presented to the University of Rochester-Strong
Memorial Hospital emergency room. She reported “right extremity pain since flu
vaccine 21 days ago,” upon undergoing an ultrasound, which was unrevealing. Ex.
3 at 17. An x-ray revealed calcific tendinopathy. Id. at 19.
6 Petitioner returned repeatedly to the primary care practice, meeting specifically with Dr. Lineman, for her
persistent right shoulder pain. The medical records reflect Petitioner’s continued concern that the injury was
caused by the subject flu vaccine – but no additional notations about the specific onset of the injury. See,
e.g., Ex. 2 at 7-8. 18-19, 26-28, 29-30.
6

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 7 of 9
• Dr. Lineman referred Petitioner for a course of physical therapy (“PT”). Ex. 2 at 29-
30. The December 12, 2018, PT initial assessment lists the mechanism of injury
as “Flu shot – 2 days later could not move her arm.” Ex. 4 at 20 (emphasis
added). However, the PT record also lists the injury onset as 10/20/18. Id.
(emphasis added).7
• After Petitioner’s pain persisted for over a year (despite the aforementioned PT,
and two steroid injections), Dr. Lineman entered a referral to orthopedics. Ex. 2 at
7-8. At the December 12, 2019, orthopedics initial consultation, a physician
assistant (“PA”) recorded Petitioner’s history of “pain since a flu shot… in
October 2018. She had immediate reaction with increased swelling, redness,
and the inability to use her arm.” Ex. 5 at 33.8
• Petitioner has not submitted any additional contemporaneous evidence, or any
later recollections, pertaining to onset. Her affidavit, required under the Vaccine
Act, does not address the question. Ex. 8.
I acknowledge that the standard applied to resolving onset for an alleged SIRVA
is liberal and will often permit a determination in a petitioner’s favor, especially in the
absence of fairly contemporaneous and direct statements to the contrary within the
contemporaneous medical records. However, not every case can be so preponderantly
established. Ultimately, the resolution of onset involves weighing different pieces of
evidence found within the specific case record (supplemented by witness statements and
other independent items).
Here, Petitioner suggests that the first notation of onset as “3 days after flu shot”
(Ex. 2 at 33) may have been recorded sometime after that telephone call, even two days
later (in conjunction with the first office visit). Brief at 7. She emphasizes that the
telephone encounter note provides that “[the primary care] office recommended Tylenol
and heat – no help.” This may have been a suggestion of common conservative
treatments, which Petitioner had in fact tried independently, prior to the call. Respondent
argues that the telephone encounter note was most likely recorded contemporaneously,
then copied into the office visit record. Response at 2-3.
7 After six formal PT sessions, Petitioner was discharged to a home exercise program on February 22,
2019. The PT records do not contain additional information relevant to my onset determination. Ex. 4 at 13-
147.
8 Petitioner subsequently underwent an MRI of the right shoulder with findings including tendinopathy and
bursal tearing; followed up with an orthopedic surgeon; and underwent arthroscopic surgery and post-
operative PT. See Ex. 6 at 35; Ex. 5 at 55; Ex. 7 at 59; Ex. 9 at 200-392.
7

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 8 of 9
But even crediting Petitioner’s argument, the available evidence supports that both
the telephone call and the office visit were with the same primary care physician, Dr.
Lavender. See Ex. 2 at 33 (reflecting that “writer spoke to patient over weekend…”). This
is also the most contemporaneous evidence – from less than two weeks post-vaccination.
Dr. Lavender’s “telephone encounter” note of onset “3 days after flu vaccine” does not
contradict his office note of onset “following flu shot a week prior,” or even necessarily his
assessment that the flu vaccine had caused an inflammatory reaction. This evidence thus
warrants significant weight.
I recognize that just nineteen (19) days later, a different primary care physician
recorded onset as having occurred 48 hours after vaccination. Ex. 2 at 31. Respondent
argues that it would be an absurd result for “typical” acute injection site soreness to
represent the onset of a Table SIRVA, see Response at 2. However, Respondent does
not grapple with the detail that Petitioner maintains that she “could not move her right arm
at all” during that timeframe. This would suggest post-vaccination pain that was unusually
severe. Standing alone, such a notation would likely support a favorable Table SIRVA
onset determination. However, this record is in direct tension with the earlier notation that
the pain began “3 days after flu shot” – which I find to be more probative.
The remaining medical records were created later in time, and state more
generally that the shoulder injury occurred “since” or “following” the vaccination. They do
not demonstrate that onset was specifically within 48 hours. Petitioner has also declined
to provide any contemporaneous non-medical evidence or later recollections that may
have shed additional light on the circumstances (although those of course, would have
had to be particularly compelling to outweigh the very detailed contemporaneous medical
records). The evidence before me thus supports the determination that onset occurred
most likely after 48 hours, but not less than 72 hours after vaccination – too long for a
successful Table claim.
Conclusion and Scheduling Order
The above factual finding dictates DISMISSAL of Petitioner’s Table SIRVA claim.
I note, however, that Petitioner has a potential causation-in-fact claim, which has
some support within the existing medical record. See, e.g., Ex. 2 at 33 (Dr. Lavender’s
endorsement that the vaccination triggered inflammation and/or nervous system
stimulation, notwithstanding his understanding of a three-day onset). Respondent’s Rule
4(c) Report does not analyze the viability of a non-Table claim.
8

Case 1:20-vv-01340-UNJ Document 38 Filed 09/11/23 Page 9 of 9
A non-Table claim could potentially include symptoms not limited to the shoulder,
if adequately explained. See Rule 4(c) at 6, Response at 2-3 (averring that Petitioner’s
complaints of pain radiating down the arm were incompatible with a Table claim, citing 42
C.F.R. § 100.3(c)(10)(iii)). However, a non-Table claim would likely require expert
support9 – which I am not inclined to authorize while the case remains in SPU.
Before transferring the case out of SPU for further proceedings, I will allow the
parties a brief opportunity to revisit their settlement discussions.
The parties are hereby ORDERED to file a joint status report indicating
whether they believe an informal resolution can be reached and providing their
preferred next step(s) in the case within 60 days, by no later than Tuesday, October
10, 2023.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
9 See, e.g.:
• Morris v. Sec’y of Health & Human Servs., 19-1570V, 2023 WL 5092691 (Fed. Cl. Spec. Mstr. July
11, 2023) (concluding in a non-SPU case, upon consideration of the petitioner’s unrebutted medical
expert opinions, that she had established causation-in-fact for persistent shoulder pain beginning
beyond 48 hours, but within 72 hours after vaccination).
• Lee v. Sec’y of Health & Hum. Servs., No. 18-0486V, 2023 WL 4444843 (Fed. Cl. Spec. Mstr. June
16, 2023) (concluding in a non-SPU case, that the petitioner had not established causation-in-fact
for persistent shoulder pain beginning approximately 4 days post-vaccination, and noting
alternative explanation of cervical radiculopathy).
9

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DOCUMENT 2: USCOURTS-cofc-1_20-vv-01340-1
Date issued/filed: 2025-10-06
Pages: 19
Docket text: PUBLIC ORDER/RULING (Originally filed: 09/10/2025) regarding 56 Ruling on Entitlement. Signed by Special Master Daniel T. Horner. (cd) Service on parties made.
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Case 1:20-vv-01340-UNJ Document 58 Filed 10/06/25 Page 1 of 19
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1340V
Filed: September 10, 2025
Special Master Horner
TERESA MAZZA,
Petitioner,
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for petitioner.
Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for respondent.
RULING ON ENTITLEMENT1
On October 7, 2020, petitioner filed a petition under the National Childhood
Vaccine Injury Act, 42 U.S.C. § 300aa, et seq. (2012) (“Vaccine Act”),2 alleging that she
suffered a right shoulder injury as a result of an influenza (“flu”) vaccination she
received on October 11, 2018. (ECF No. 1.) For the reasons set forth below, I
conclude that petitioner is entitled to compensation.
I. Applicable Statutory Scheme
Under the National Vaccine Injury Compensation Program, compensation
awards are made to individuals who have suffered injuries after receiving vaccines. In
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;
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

Case 1:20-vv-01340-UNJ Document 58 Filed 10/06/25 Page 2 of 19
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 Shoulder Injury Related to
Vaccine Administration (“SIRVA”) as a compensable injury if it occurs within ≤48 hours
of administration of a flu vaccine. § 300aa-14(a), amended by 42 C.F.R. § 100.3. Table
Injury cases are guided by a statutory “Qualifications and aids in interpretation” (“QAI”),
which provide more detailed explanation of what should be considered when
determining whether a petitioner has actually suffered an injury listed on the Vaccine
Injury Table. § 300aa-14(a). To be considered a Table SIRVA petitioner must show
that his/her injury fits within the following definition:
SIRVA manifests as shoulder pain and limited range of motion occurring
after the administration of a vaccine intended for intramuscular
administration in the upper arm. These symptoms are thought to occur as
a result of unintended injection of vaccine antigen or trauma from the needle
into and around the underlying bursa of the shoulder resulting in an
inflammatory reaction. SIRVA is caused by an injury to the musculoskeletal
structures of the shoulder (e.g. tendons, ligaments, bursae, etc.). SIRVA is
not a neurological injury and abnormalities on neurological examination or
nerve conduction studies (NCS) and/or electromyographic (EMG) studies
would not support SIRVA as a diagnosis . . . A vaccine recipient shall be
considered to have suffered SIRVA if such recipient manifests all of the
following:
(i) No history of pain, inflammation or dysfunction of the affected
shoulder prior to intramuscular vaccine administration that would
explain the alleged signs, symptoms, examination findings, and/or
diagnostic studies occurring after vaccine injection;
(ii) Pain occurs within the specified time-frame;
(iii) Pain and reduced range of motion are limited to the shoulder in which
the intramuscular vaccine was administered; and
2

Case 1:20-vv-01340-UNJ Document 58 Filed 10/06/25 Page 3 of 19
(iv) No other condition or abnormality is present that would explain the
patient’s symptoms (e.g. NCS/EMG or clinical evidence of
radiculopathy, brachial neuritis, mononeuropathies, and any other
neuropathy).
42 C.F.R. § 100.3(c)(10).
Alternatively, if no injury falling within the Table can be shown, a petitioner could
still demonstrate entitlement to an award by instead showing that the vaccine recipient’s
injury or death was caused-in-fact by the vaccination in question. § 300aa-13(a)(1)(A);
§ 300aa-11(c)(1)(C)(ii). In particular, a petitioner must demonstrate that the vaccine
was “not only [the] but-for cause of the injury but also a substantial factor in bringing
about the injury.” Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1321-22
(Fed. Cir. 2010) (quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344,
1352-53 (Fed. Cir. 1999)); Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352,
1355 (Fed. Cir. 2006). To successfully demonstrate causation-in-fact, petitioner bears a
burden to show: (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. 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 bear a
“preponderance of the evidence” burden of proof. § 300aa-13(1)(a). That is, a
petitioner must offer evidence that leads the “trier of fact to believe that the existence of
a fact is more probable than its nonexistence before [he] may find in favor of the party
who has the burden to persuade the judge of the fact’s existence.” Moberly, 592 F.3d at
1322 n.2 (alternation in original); see also Snowbank Enters., Inc. v. United States, 6 Cl.
Ct. 476, 486 (1984) (explaining that mere conjecture or speculation is insufficient under
a preponderance standard). Proof of medical certainty is not required. Bunting v. Sec’y
of Health & Human Servs., 931 F.2d 867, 873 (Fed. Cir. 1991). However, a petitioner
may not receive a Vaccine Program award based solely on her assertions; rather, the
petition must be supported by either medical records or by the opinion of a competent
physician. § 300aa-13(a)(1).
Cases in the Vaccine Program are assigned to special masters who are
responsible for “conducting all proceedings, including taking such evidence as may be
appropriate, making the requisite findings of fact and conclusions of law, preparing a
decision, and determining the amount of compensation, if any, to be awarded.” Vaccine
Rule 3(b)(1). Special masters must ensure each party has had a “full and fair
opportunity” to develop the record. Vaccine Rule 3(b)(2). However, special masters are
empowered to determine the format for taking evidence based on the circumstances of
each case. Vaccine Rule 8(a); Vaccine Rule 8(d). Special masters are not bound by
common law or statutory rules of evidence but must consider all relevant and reliable
evidence in keeping with fundamental fairness to both parties. Vaccine Rule 8(b)(1).
The special master is required to consider “all [] relevant medical and scientific evidence
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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). The special
master is required to consider all the relevant evidence of record, draw plausible
inferences, and articulate a rational basis for the decision. Winkler v. Sec’y of Health &
Human Servs., 88 F.4th 958, 963 (Fed. Cir. 2023) (citing Hines ex rel. Sevier v. Sec’y of
Health & Human Servs., 940 F.2d 1518, 1528 (Fed. Cir. 1991)).
II. Procedural History
This case was originally assigned to the Chief Special Master as part of the
Special Processing Unit (“SPU”). (ECF Nos. 8-9.) Petitioner initially filed medical
records marked as Exhibits 1-7 and an affidavit marked as Exhibit 8. (ECF No. 1.) She
subsequently filed additional medical records marked as Exhibits 9-10 and her
statement of completion in November of 2020. (ECF Nos. 11-12.) In June of 2021, she
filed further records marked Exhibit 11, and an amended statement of completion.
(ECF Nos. 20-21.)
The parties explored settlement from November of 2021 through May of 2022.
(ECF Nos. 24-29.) After reaching an impasse (ECF No. 29), respondent filed his Rule
4(c) Report in June of 2022. (ECF No. 30.) Respondent argued that petitioner could
not meet the second QAI criterion for a Table SIRVA (onset) or the third (pain and
reduced motion limited to the affected shoulder). (Id. at 6.) Additionally, without an
expert opinion, respondent contended that petitioner’s medical records were inadequate
to meet petitioner’s burden with respect to a shoulder injury caused-in-fact by her
vaccination. (Id. at 7.)
After briefing, the Chief Special Master issued Findings of Fact and Conclusions
of Law on August 10, 2023, dismissing petitioner’s Table SIRVA claim. (ECF No. 37;
Mazza v. Sec’y of Health & Human Servs., No. 20-1340V, 2023 WL 5844787 (Fed. Cl.
Spec. Mstr. Aug. 10, 2023).) Specifically, the Chief Special Master found that onset of
petitioner’s shoulder pain occurred “not less than 72 hours after vaccination,” which is
incompatible with a Table SIRVA. (ECF No. 37, p. 8; 2023 WL 5844787, at *5.) He did
not reach any conclusion with respect to respondent’s argument that symptoms were
not limited to the affected shoulder, noting that this issue would not necessarily be
dispositive of a cause-in-fact claim. (ECF No. 37, p. 9; 2023 WL 5844787, at *6.)
After dismissal of the Table claim, the case was reassigned to the undersigned in
October of 2023 for litigation of the remaining cause-in-fact claim. (ECF Nos. 39-41.)
Petitioner then filed an expert report by physical medicine and rehabilitation specialist
Naveed Natanzi, D.O. (ECF No. 43; Exs. 12-35.) Respondent responded with a report
by orthopedic surgeon Geoffrey Abrams, M.D. (ECF No. 45; Exs. A-B.) Thereafter, the
parties exchanged a second round of expert reports (ECF Nos. 47, 49; Exs. 36, C),
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before confirming that the case was ripe for briefing pursuant to Vaccine Rule 8(d) (ECF
No. 50).
Petitioner then filed a motion for a ruling on the written record on August 14,
2024. (ECF No. 51.) Respondent filed his response on November 1, 2024, which also
included a cross-motion for a decision dismissing the petition. (ECF No. 54.) Petitioner
filed a reply on November 18, 2024. (ECF No. 55.)
I have determined that the parties have had a full and fair opportunity to present
their cases and that it is appropriate to resolve entitlement on the existing record. See
Vaccine Rule 8(d); Vaccine Rule 3(b)(2); see also 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 ripe for resolution.
III. Factual History
Petitioner received the flu vaccination at issue in her right arm on October 11,
2018. (Ex. 1, p. 2.) Prior to the vaccination, she did have a history of neck pain and
epicondylitis. (Ex. 2, pp. 39-45.) The factual history with respect to the initial onset of
petitioner’s post-vaccination pain is explained in the prior finding of fact and will not be
repeated. (ECF No. 37; 2023 WL 5844787.)
Petitioner first presented to her primary care provider, Dr. Lavender, for care of
her alleged SIRVA on October 22, 2018. (Ex. 2, p. 33.) She presented with a report of
right arm pain that was noted to be suspicious for neuropathic pain. (Id.) The pain had
initially radiated to her hand, but by the time of her medical appointment was radiating
only as far as the elbow. (Id.) On physical examination, she had normal range of motion
of her right arm, active and passive, though she had reproducible lateral upper arm
pain. (Id. at 34.) Additionally, she had tenderness over the deltoid. (Id.) She was
assessed as having “right arm pain” and Dr. Lavender additionally noted that “I
explained that pain is likely related to localized inflammation triggered by the
immunization, with possible stimulation of adjacent nervous system structures resulting
in pain.” (Id.) Dr. Lavender recommended gabapentin, but petitioner declined. She
was advised to keep her right arm active and to follow up as needed. (Id.)
Petitioner returned to her primary care provider eight days later, on October 30,
2018, this time seeing Dr. Lineman. (Ex. 2, p. 31.) Petitioner reported having problems
with her range of motion in her right shoulder, suggesting she felt “stiff.” (Id.) She also
reported shooting pain radiating down into her bicep. (Id.) On physical examination,
petitioner was again documented as having full range of motion, albeit with some pain
with abduction. (Id.) However, “some mild impingement signs” were noted. (Id.)
Petitioner’s assessment was again limited to “right arm pain/shoulder pain.” (Id.) Dr.
Lineman indicated:
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Discussed with patient that some of her symptoms may be related [to] an
exaggerated immune response to the influenza vaccination, but I actually
suspected that her right shoulder pain is musculoskeletal in nature. This
may be related to some mild rotator cuff irritation.
(Id.) Dr. Lineman prescribed gabapentin and recommended shoulder exercises for
rotator cuff irritation. (Id.)
Dr. Lineman had planned to follow up in two weeks (Ex. 2, pp. 31-32); however,
petitioner presented to the emergency department the next day for severe deltoid pain
(Ex. 3, pp. 17-20; see also Ex. 2, p. 29). She was evaluated to see if her right deltoid
pain was due to an abscess. (Ex. 3, p. 17.) A targeted ultrasound of her right deltoid
showed no fluid collection or mass. (Id. at 17-18.) An x-ray of her right shoulder
showed “mild degenerative changes of the acromial clavicular joint. Opacification at the
level of the tuberosities is likely secondary to calcific tendinopathy.” (Id. at 19.) There’s
no indication that petitioner’s range of motion was evaluated. (See id. at 17-20.)
Petitioner returned to Dr. Lineman on November 13, 2018. (Ex. 2, p. 29.) She
reported that her x-ray did show some calcified tendinitis but also noted that her range
of motion was improving. (Id.) Dr. Lineman did not perform any physical exam of
petitioner’s shoulder at this encounter (“MSK: Performed at last visit”). (Id.) She
assessed right rotator cuff tendinitis and indicated that “I suspect that she likely had
some discomfort in her right deltoid after her influenza vaccination, but it seems that her
main pain has resulted from tendinitis.” (Id.) Petitioner was referred to physical
therapy. (Id. at 29-30.)
On December 12, 2018, petitioner presented for her initial evaluation for physical
therapy. (Ex. 4, pp. 12-23.) At that time, she had reduced range of motion in her right
shoulder, with flexion of 130 degrees and external rotation to 32 degrees. (Id. at 20-21.)
She had internal rotation to the hip. (Id.) She had seven sessions of physical therapy
between December of 2018 and February of 2019. (Id. at 137, 140.) By the end of her
physical therapy, her flexion had increased to 162 degrees and her external rotation to
85 degrees. (Id. at 139-40.) Internal rotation was up to T8. (Id. at 139.)
She returned to Dr. Lineman on March 22, 2019. (Ex. 2, pp. 26-27.) Petitioner
confirmed that she had improved significantly with physical therapy, but noted that she
was still bothered by pain, especially with overhead lifting. (Id. at 27.) She reported
struggling with her home exercises, indicating that they increased her pain. (Id.)
Petitioner was given a steroid injection. (Id. at 26-27.) Dr. Lineman also recorded that
“[a]gain I tried to stress with patient that I did not believe her symptoms are related to
her previous influenza vaccination, but patient perseverates on this idea.” (Id. at 27.)
In April, May, and June of 2019, petitioner had unrelated primary care
encounters. (Ex. 2, pp. 21-25.) On June 6, 2019, she reported to Dr. Lineman among
other things that, although the steroid injection had helped “significantly,” her pain had
recently started to return. (Id. at 18.) Having noted rotator cuff tendinitis to be a “known
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diagnosis” for petitioner, there’s no indication that Dr. Lineman performed any
examination of petitioner’s right shoulder. (Id. at 19.) She was encouraged to continue
home exercises, take naproxen, and follow up in one month. (Id.) She returned on
August 23, 2019, reporting that her arm continues to feel “achy and sore” and received
a second steroid injection. (Id. at 15-16.) On November 19, 2019, she requested a
third steroid injection, but this request was denied as premature, and she was instead
referred to an orthopedist. (Id. at 7-8.)
Petitioner presented to an orthopedic specialist (P.A. Bradt) on December 12,
2019. (Ex. 5, pp. 33-34.) P.A. Bradt recorded petitioner’s history of a post-vaccination
onset and also noted she had been diagnosed with calcific tendinitis, which had been
treated conservatively up to that point. (Id. at 33.) On physical exam, petitioner had
active forward elevation to 160 degrees and external rotation to 60 degrees. (Id.) Her
deltoid was noted as “functional.” (Id.) She had reduced strength (4/5) with forward
flexion as well as internal and external rotation. (Id.) Hawkins, Neer, and O’Brian
testing was positive, and she had tenderness along the biceps tendon. (Id. at 33-34.)
Petitioner had new x-rays and P.A. Bradt compared them against her prior x-rays,
observing that the previously identified calcium deposits had resolved but that a new
deposit was present in the posterior rotator cuff. (Id. at 34.) Petitioner was assessed as
having “right shoulder calcific tendinosis, impingement, pain.” (Id.) However, P.A. Bradt
was also “concerned for a rotator cuff tear” and therefore ordered an MRI. (Id.)
Petitioner underwent a right shoulder MRI on December 28, 2019. (Ex. 6, pp.
35-40.) The radiologist’s impression was (1) mild distal supraspinatus tendinopathy; (2)
moderate bursal sided tearing of the distal infraspinatus tendon with a hypointense
focus along the insertion, which “may represent calcific tendinopathy”; and (3) focal
thinning of the inferior half of the thyroid cartilage.” (Id. at 38.) Petitioner then
presented to an orthopedic surgeon (Dr. Voloshin) on January 7, 2020. (Ex. 5, pp. 49-
55.) Based on petitioner’s history, physical exam, and MRI findings, Dr. Voloshin
assessed petitioner as having “persistent calcific tendinitis, partial rotator cuff tear, and
subacromial impingement syndrome.” (Id. at 55.) Because petitioner had failed
conservative measures, an arthroscopic surgery was recommended, with specific
procedures depending on the surgical findings.3 (Id.)
Petitioner underwent surgery on May 18, 2020. (Ex. 7, pp. 59-63.) Dr. Voloshin
noted the indications for surgery to be “partial-thickness rotator cuff tear[,] subacromial
impingement syndrome[,] as well as possible calcific tendonitis.” (Id.) During the
surgery, “[t]he patient was noted to have significant subacromial bursitis” and she
underwent an “extensive debridement of subacromial bursa in the subacromial space.”
(Id. at 60.) It was also noted that “[o]n the bursal side with a spinal needle, the rotator
cuff was thoroughly inspected. There was no evidence of calcium deposit. However,
the patient did have a high-grade partial supraspinatus tear,” which was repaired. (Id.)
3 Specifically, “She was proposed to have right shoulder arthroscopic subacromial decompression,
debridement of glenohumeral joint depending on the findings, debridement of the calcium deposit,
possible rotator cuff repair, possible biceps tenodesis if biceps damage is found.” (Ex. 5, p. 55.)
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The following surgical procedures were noted: (1) rotator cuff repair; (2) “extensive
glenohumeral joint debridement with debridement of degenerative labral tearing
circumferentially to stable rim with a shaver[,]” “debridement of grade 2 chondral
damage in the humeral head and the glenoid[,]” “debridement of the frayed portion of
the torn supraspinatus[,]” and “extensive debridement of subacromial bursa in the
subacromial space for bursitis (separate compartments with debridement of the different
tissue types)”; and (3) acromioplasty. (Id. at 59.)
Although this was not the end of petitioner’s treatment, the remaining medical
records are generally not informative with respect to the issues addressed herein.
However, once petitioner completed her surgery, calcific tendinitis was no longer
included in her orthopedic treatment records as part of the description of the
pathophysiology of her condition. (See generally Exs. 10-11.)
IV. Expert Opinions
a. Naveed Natanzi, D.O., for petitioner4
Although Dr. Natanzi acknowledged that one of petitioner’s medical treatment
records indicated that onset of her condition occurred three days post-vaccination, he
opines that on balance the medical records reflect that the majority of her symptoms
occurred between 24 and 48 hours after her vaccination, which is consistent with the
Table SIRVA requirements. (Ex. 12, p. 4 (citing Ex. 2, pp.31, 33; Ex. 4, p. 20).)
However, he also observes that SIRVA is a syndrome and not a true medical diagnosis.
(Id. at 5.) In that regard, he notes that a study by Cagle observed that among 56
patients reporting post-vaccination shoulder injuries, 16% reported onset of pain
occurring after 48 hours. (Id. (citing Paul J. Cagle Jr., Shoulder Injury After Vaccination:
A Systematic Review, REVISTA BRASILEIRA DE ORTOPEDIA (Dec. 16, 2020) (Ex. 35)).)
Thus, Dr. Natanzi confirms that he would still attribute petitioner’s condition to her
vaccination even if onset occurred about 72 hours post-vaccination. (Id.)
Further to this, Dr. Natanzi observes that petitioner had no prior documented
history of right shoulder pain or dysfunction. (Id.) Yet, within days of her vaccination,
she had restricted range of motion and signs of subacromial impingement. (Id. (citing
Ex. 4, p. 20; Ex. 2, p. 31; Ex. 5, p. 54).) Moreover, in addition to degenerative changes,
4 Dr. Natanzi received his Doctor of Osteopathy in 2012 from Western University of Health Sciences in
Pomona, California. (Ex. 13, p. 2.) In 2013, he completed a traditional rotating internship at Downey
Regional Medical Center in Downey, California. (Id. at 1.) Thereafter, Dr. Natanzi completed a residency
in physical medical and rehabilitation at the University of California, Irvine, serving as chief resident in his
final year. (Id.) In 2017, he went on to complete a fellowship at the Bodor Clinic in Napa, California. (Id.)
Dr. Natanzi is board-certified in physical medicine and rehabilitation and pain management, and he
maintains his license to practice medicine in California. (Id. at 1, 4; Ex. 12, p. 1.) Currently, he serves as
a staff physician at VA Long Beach Healthcare System and is the founder of the Regenerative Sports and
Spine Institute in Sherman Oaks, California. (Ex. 13, p. 1.) Dr. Natanzi has submitted seven
publications. (Id. at 3.)
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her surgical findings confirmed “extensive subacromial bursitis.” (Id. (citing Ex. 5, p.
54).) Dr. Natanzi characterizes this as a “classic” SIRVA presentation. (Id.)
Additionally, Dr. Natanzi indicates that “the medical literature describes dozens of
cases of immune-mediated inflammatory reactions as a result of vaccine
administration.”5 (Ex. 12, p. 6.) Based on this literature, he summarizes a theory of
causation as follows:
5 Specifically, Dr. Natanzi cites: S. Atanasoff et al., Shoulder Injury Related to Vaccine Administration
(SIRVA), 28 VACCINE 8049 (2010) (Ex. 14); Marko Bodor & Enoch Montalvo, Vaccination-Related
Shoulder Dysfunction, 25 VACCINE 585 (2007) (Ex. 15); Matthew G. Barnes et al., A “Needling” Problem:
Shoulder Injury Related to Vaccine Administration, 25 J. AM. BD. FAM. MED. 919 (2012) (Ex. 16); Ian F.
Cook, Subdeltoid/Subacromial Bursitis Associated with Influenza Vaccination, 10 HUM. VACCINES &
IMMUNOTHERAPEUTICS 605 (2014) (Ex. 17); Alexandria Wright et al., Influenza Vaccine-Related
Subacromial/Subdeltoid Bursitis: A Case Report, 13 J RADIOLOGY CASE REPS. 24 (2019) (Ex. 18); I.
Degreef & Ph. Debeer, Post-Vaccination Frozen Shoulder Syndrome: Report of 3 Cases, 112 ACTA
CHIRURGICA BELGICA 447 (2012) (Ex. 19); Zeina M. Saleh et al., Onset of Frozen Shoulder Following
Pneumococcal and Influenza Vaccinations, 14 J. CHIROPRACTIC MED. 285 (2015) (Ex. 20); Brian P.
McColgan & Frank Borschke, Pseudoseptic Arthritis After Accidental Intra-Articular Deposition of the
Pneumococcal Polyvalent Vaccine: A Case Report, 25 AM. J. EMERGENCY MED. 864.e1 (2007) (Ex. 21);
Gokcan Okur et al., Magnetic Resonance Imaging of Abnormal Shoulder Pain Following Influenza
Vaccination, 43 SKELETAL RADIOLOGY 1325 (2014) (Ex. 22); C. Trollmo et al., Intra-Articular Immunization
Induces Strong Systemic Immune Response in Humans, 82 CLINICAL & EXPERIMENTAL IMMUNOLOGY 384
(1990) (Ex. 23); Ian F. Cook, An Evidence Based Protocol for the Prevention of Upper Arm Injury Related
to Vaccine Administration (UAIRVA), 7 HUM. VACCINES 845 (2011) (Ex. 24); Christopher V. Macomb et al.,
Treating SIRVA Early with Corticosteroid Injections: A Case Series, MIL. MED., 2019, at 1 (Ex. 25); Soshi
Uchida et al., Subacromial Bursitis Following Human Papilloma Virus Vaccine Misinjection, 31 VACCINE
27 (2012) (Ex. 26); L.H. Martín Arias et al., Risk of Bursitis and Other Injuries and Dysfunctions of the
Shoulder Following Vaccinations, 35 VACCINE 4870 (2017) (Ex. 27); Alexandra Wright et al., Influenza
Vaccine-Related Subacromial/Subdeltoid Bursitis: A Case Report, 13 J. RADIOLOGY CASE REPS. 24
(2019) (Ex. 28); Maj Sofia Szari et al., Shoulder Injury Related to Vaccine Administration: A Rare
Reaction, 2019 FED. PRAC. 380 (Ex. 29); Michael Shahbaz et al., Shoulder Injury Related to Vaccine
Administration (SIRVA): An Occupational Case Report, 67 WORKPLACE HEALTH & SAFETY 501 (2019) (Ex.
30); J.H. Salmon et al., Bone Erosion and Subacromial Bursitis Caused by Diphtheria-Tetanus-
Poliomyelitis Vaccine, 33 VACCINE 6152 (2015) (Ex. 31); Naveed Natanzi et al., Teres Minor Injury
Related to Vaccine Administration, 15 RADIOLOGY CASE REPS. 552 (2020) (Ex. 32); Gail B. Cross et al.,
Don’t Aim Too High: Avoiding Shoulder Injury Related to Vaccine Administration, 45 AUSTL. FAM.
PHYSICIAN 303 (2016) (Ex. 33).
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In his second report, Dr. Natanzi addresses Dr. Abrams’s suggestion that
petitioner’s correct diagnosis is calcific tendinitis (referred to by Dr. Natanzi as calcific
tendinopathy). (Ex. 36.) Dr. Natanzi acknowledges that the radiologist interpreted both
petitioner’s October 31, 2018 x-ray and December 28, 2019 MRI as potentially
indicating calcific tendinitis. (Id. at 1 (citing Ex. 3, p. 19; Ex. 6, p. 39).) However, he
stresses that during petitioner’s subsequent surgery it was explicitly confirmed that
“there was no evidence of calcium deposit.” (Id. (citing Ex. 7, p. 59).) Dr. Natanzi
contends that the surgical findings should be viewed as more reliable than the radiology
reports. (Id.) Moreover, even if petitioner did have calcific tendinitis that resolved (i.e.
the calcium deposits self-reabsorbed) prior to her surgery, the fact that she nonetheless
remained symptomatic and required surgery would suggest that any calcific tendinitis
that was present was not the source of her pain. (Id.)
b. Geoffrey Abrams, M.D., for respondent6
Dr. Abrams opines that petitioner’s shoulder pain cannot be attributed to her
vaccination for two primary reasons. (Ex. A, p. 6.) First, petitioner did not demonstrate
limited range of motion on physical exam until nearly two months post-vaccination,
which would be “highly unusual” for SIRVA. (Id.) At a minimum, petitioner’s clinical
course confirms that she had normal range of motion for nearly three weeks post-
vaccination. (Id. (citing Ex. 2, pp. 31, 33; Ex. 4, p. 20).) However, Dr. Abrams stresses
that within the literature cited by Dr. Natanzi, “loss of range of motion is almost aways
immediately documented following vaccination.” (Id. at 6-7 (citing Atanasoff et al.,
supra, at Ex. 14; Bodor & Montalvo, supra, at Ex. 15; Cook, supra, at Ex. 17; Wright et
al., supra, at Ex. 18; Saleh et al., supra, at Ex. 20; Macomb et al., supra, at Ex. 25;
Uchida et al., supra, at Ex. 26; Szari et al., supra, at Ex. 29; Shahbaz et al., supra, at
Ex. 30; Cross et al., supra, at Ex. 33; Cagle, supra, at Ex. 35).)
Second, he opines that petitioner’s symptoms are explained by documented
calcific tendinitis. (Ex. A, pp. 7-8.) Dr. Abrams notes that petitioner’s imaging indicates
she had calcific tendinitis. (Id. at 7 (citing Ex. 3, p. 19; Ex. 6, p. 35).) He explains that
this condition is a frequent cause of shoulder pain and also appears in only 2.7% of
non-painful shoulders, meaning it is unlikely to be an incidental finding. (Id. at 7-8
(citing Christelle Darrieutort-Laffite et al., Calcific Tendonitis of the Rotator Cuff: From
Formation to Resorption, 85 JOINT BONE SPINE 687 (2018) (Ex. A, Tab 1); Harrison L.
McLaughlin, Lesions of the Musculotendinous Cuff of the Shoulder: III. Observations on
6 Dr. Abrams received his medical degree from the University of California, San Diego in 2007. (Ex. B, p.
1.) He completed an internship in general surgery and a residency in orthopedic surgery at Stanford
University Hospital and Clinics in 2008 and 2012 respectively. (Id.) Thereafter, Dr. Abrams went on to
complete a fellowship in orthopedic sports medicine at Rush University Medical Center, where he also
worked as a clinical instructor, in 2013. (Id.) After finishing his fellowship, Dr. Abrams returned to
Stanford University School of Medicine where he is currently an Assistant Professor and Director of the
Lacob Sports Medicine Clinic. (Id.) Additionally, he also serves as an attending physician at the
Veterans Administration Hospital in Palo Alto, California. (Id.) He is board-certified in orthopedic surgery,
and he maintains an active medical license in California. Throughout his career, Dr. Abrams has
authored over 150 peer-reviewed publications and abstracts, 28 podium and poster presentations, 5
commentaries, and 26 book chapters. (Id. at 2-22.)
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the Pathology, Course and Treatment of Calcific Deposits, 124 ANNALS SURGERY 354
(1946) (Ex. A, Tab 2)).) Dr. Abrams contends that, whereas SIRVA generally involves
an abrupt onset of reduced range of motion, calcific tendinitis typically results in a more
gradual loss of motion. (Id. at 8.) Thus, he opines that petitioner’s clinical presentation
is more consistent with calcific tendinitis than SIRVA. (Id.)
Regarding the noted lack of calcium deposits during petitioner’s surgery, Dr.
Abrams notes two points. (Ex. C, pp. 1-2.) First, calcium deposits often are not seen
on the visible surface of the tendon, requiring needle insertion into the tendon during
surgery. (Id. at 1.) Second, even accounting for the fact that this may have been done
in petitioner’s own surgery, “it is easy to miss small to medium size lesions.” (Id.) Dr.
Abrams further stresses that the most painful stage of calcific tendinitis is the resorptive
phase, wherein calcium deposits are removed by a localized inflammatory process. (Id.
at 2.) Because petitioner had a course of shoulder pain prior to surgery, it would be
reasonable to conclude that she was already in the resorptive phase prior to surgery.
(Id.) Dr. Abrams concludes that petitioner’s surgical finds “in no way exclude” calcific
tendinitis as the source of petitioner’s pain. (Id.)
V. Party Contentions
Petitioner argues that Dr. Natanzi’s expert report supports a cause-in-fact claim
for the condition of post-vaccination subacromial bursitis. (ECF No. 51, p. 7 (citing Ex.
12, p. 5; Ex. 7, p. 49).) Although Dr. Abrams opined that the correct diagnosis was
calcific tendinitis, petitioner argues that this condition was never definitively diagnosed
by her treaters and was ruled out by her surgical findings. (Id. at 8.)
Regarding Althen prong one, petitioner argues that it is well established by prior
program cases that shoulder injuries can be caused-in-fact by vaccination, and stresses
that Dr. Abrams did not challenge Dr. Natanzi’s theory that needle penetration into the
subacromial bursa can cause bursitis. (ECF No. 51, pp. 8-9.) Moreover, Dr. Natanzi’s
theory is supported by medical literature. (Id. at 9 (citing Atanasoff et al., supra, at Ex.
14; Cook, supra, at Ex. 17; Wright et al., supra, at Ex. 18; Bodor & Montalvo, supra, at
Ex. 15.).)
Regarding Althen prong two, petitioner argues that, in addition to Dr. Natanzi’s
supporting expert opinion, two of her treating physicians likewise attributed her condition
to her vaccination. (ECF No. 51, p. 10.) Specifically, Dr. Lavender recorded that
petitioner’s shoulder pain was “likely related to localized inflammation triggered by the
immunization.” (Id. (quoting Ex. 2, p. 34).) Additionally, Dr. Lineman indicated that
petitioner’s symptoms “may be related from an exaggerated immune response to the
influenza vaccination.” (Id. (quoting Ex. 2, p. 31).)
Regarding Althen prong three, petitioner first suggests that the Chief Special
Master’s fact finding is not binding, implicitly arguing that onset should be found to have
been within 48 hours of vaccination. (ECF No. 51, p. 11.) However, discussing Dr.
Natanzi’s expert opinion and citing the literature he referenced, petitioner also argues
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that the 48-hour onset period should not be treated as an “absolute.” (Id. at 12 (citing
Cagle, supra, at Ex. 35, p. 3).) Petitioner argues that a 72-hour onset is also medically
reasonable. (Id. at 13 (citing Murray v. Sec’y of Health & Human Servs., No. 17-1357V,
2022 WL 17829797 (Fed. Cl. Spec. Mstr. Oct. 27, 2022); Pitts v. Sec’y of Health &
Human Servs., No. 18-1512V, 2023 WL 2770943 (Fed. Cl. Spec. Mstr. Apr. 4, 2023)).)
Further, she contends that respondent has not rebutted this point. (Id. at 12-13.)
Although respondent acknowledges that Dr. Natanzi opined that petitioner
suffered subacromial bursitis, he stresses that this opinion stems from petitioner’s May
18, 2020 surgery, which is remote to the initial onset of her condition. (ECF No. 54, pp.
7-10.) He argues that the diagnosis of calcific tendinitis is more reliably reached and
that, absent the ability to rely on bursitis, petitioner has not demonstrated a defined and
recognized injury that could support an Althen analysis. (Id. (citing Broekelschen v.
Sec’y of Health & Human Servs., 618 F.3d 1339, 1349 (Fed. Cir. 2010) (indicating a
claim must be based on “more than just a symptom or manifestation of an unknown
injury”); Grant v. Sec’y of Health & Human Servs., 956 F.2d 1144, 1147-48 (Fed. Cir.
1992) (indicating that similarity to a Table injury is insufficient)).)
Regarding Althen prong one, respondent acknowledges that “the Court has
accepted the hypothesis of inflammation caused by vaccine overpenetration into the
synovial space of the shoulder as a theory for SIRVA,” but contends that “the current
record does not support an injury for which a generic theory of ‘inflammation’ is
applicable.” (ECF No. 54, p. 13.) Regarding Althen prong two, even if petitioner had
succeeded in presenting a defined injury and a theory of causation, respondent
contends that the record evidence still favors calcific tendinitis as the sole source of
petitioner’s shoulder pain, preventing any demonstration of a logical sequence of cause
and effect implicating her vaccination. (Id. at 14-16 (citing Molina v. Sec’y of Health &
Human Servs., No. 20-845V, 2024 WL 4223393, at *11-12 (Fed. Cl. Spec. Mstr. Aug.
15, 2024)).) Respondent interprets the medical records as showing that petitioner’s
treating physicians were skeptical that her vaccination was a cause of her condition.
(Id. at 16.) Regarding Althen prong three, respondent argues there is no basis for
revisiting the Chief Special Master’s finding of fact and contends that Dr. Natanzi did not
adequately address the facts as found by the finding of fact. (Id. at 16-17.)
In reply, petitioner stresses that there were no findings consistent with calcific
tendinitis during petitioner’s surgery and contends that respondent’s own literature
indicates that, if petitioner did experience resorption prior to surgery, there still should
have been evidence of tendon repair, which was not noted. (ECF No. 55, pp. 2-3 (citing
Darrieutort-Laffite et al., supra, at Ex. A, Tab 1).) Petitioner refutes the notion that Dr.
Natanzi’s theory is too generic, stressing that he presented a theory specific to
subacromial bursitis, which was supported by relevant medical literature. (Id. at 4-5.)
Petitioner stresses that her clinical presentation is more consistent with an acute post-
vaccination process, noting especially the post-vaccination onset of symptoms and the
finding of bursal dysfunction upon surgery. (Id. at 5.) She reiterates that a strict 48-
hour onset is not required in a cause-in-fact context and that special masters are
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discouraged from setting “hard and fast” deadlines for onset. (Id. at 6 (citing Paluck v.
Sec’y of Health & Human Servs., 786 F.3d 1373, 1384 (Fed. Cir. 2015).)
VI. Analysis
a. Althen prong one
Under Althen prong one, petitioners 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 (quoting Pafford v. Sec’y of Health & Human Servs., No. 01-
0165V, 2004 WL 1717359, at *4 (Fed. Cl. Spec. Mstr. July 16, 2004)). 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 mechanism, or a generally accepted medical theory. See
Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1378 (Fed. Cir. 2009) (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 [their] theory.” Boatmon v. Sec’y of Health & Human Servs., 941 F.3d
1351, 1359 (Fed. Cir. 2019) (quoting Moberly, 592 F.3d at 1322). “While it does not
require medical or scientific certainty, it must still be ‘sound and reliable.’” Id. (quoting
Knudsen, 35 F.3d at 548-49).
In this case, as illustrated by the flow chart depicted above, Dr. Natanzi has
offered a theory of causation whereby needle overpenetration can result in an
inflammatory response within the bursa, leading to subacromial bursitis and attendant
symptoms of shoulder pain and dysfunction. (Ex. 12, p. 6.) And, as petitioner stresses
in her motion (ECF No. 51, pp. 9-10), this theory is also supported by relevant medical
literature, particularly medical articles by: Martín Arias et al., supra, at Ex. 27; Atanasoff
et al., supra, at Ex. 14; Cook, supra, at Ex. 17; Wright et al., supra, at Ex. 18; and Bodor
& Montalvo, supra, at Ex. 15. Respondent does not dispute Dr. Natanzi’s hypothesis,
acknowledging it has been accepted in prior cases. (ECF No. 54, p. 13 (citing A.P. v.
Sec’y of Health & Human Servs., No. 17-784V, 2022 WL 275785, at *25-27 (Fed. Cl.
Spec. Mstr. Jan. 31, 2022).) Instead, respondent argues that this theory is “too generic”
to satisfy petitioner’s burden of proof under Althen prong one given the record of this
particular case. (Id. at 13-14.)
Respondent’s argument with respect to Althen prong one is not persuasive.
Contrary to respondent’s assertion, Dr. Natanzi has demonstrated a theory of causation
relative to a specific condition, namely bursitis. Moreover, this specific condition is
relevant to petitioner’s own case, because the surgery she underwent in treatment of
her condition revealed bursitis. (Ex. 7, p. 60.) Respondent contends that petitioner
cannot reasonably associate her bursitis to her vaccination because (1) he argues it is
merely a symptom of calcific tendinitis rather than a distinct condition and (2) it was not
confirmed by her earlier, pre-surgery MRI. (ECF No. 54, pp. 8-9, 13-14.) However,
these are considerations relative to Althen prong two. Neither of these points raise a
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question as to whether a vaccination can cause bursitis or whether bursitis can support
a vaccine injury claim under appropriate circumstances.
For all of these reasons, I find that petitioner has met her preponderant burden of
proof with respect to Althen prong one relative to post-vaccination bursitis. Notably,
however, petitioner has not asserted, nor would the record support, that calcific
tendinitis can be caused by vaccination.
b. 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. 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). The explanation for what is a medically acceptable
timeframe must coincide with the theory of how the relevant vaccine can cause an injury
(Althen prong one's requirement). Id.; Shapiro v. Sec’y of Health & Human Servs., 101
Fed. Cl. 532, 542 (2011), mot. for recons. denied after remand, 105 Fed. Cl. 353 (2012),
aff’d, 503 F. App’x. 952 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Human Servs., No.
11-355V, 2013 WL 3214877, at *26 (Fed. Cl. Spec. Mstr. May 30, 2013), aff’d, 773 F.3d
1239 (Fed. Cir. 2014).
In her motion, petitioner suggests that the Chief Special Master’s finding of fact
be revisited with respect to the onset of her shoulder pain. (ECF No. 51, pp. 11-12.)
Generally, special masters may change or revisit any ruling until judgment enters, even
if the case has been transferred. See McGowan v. Sec'y of Health & Human Servs., 31
Fed. Cl. 734, 737-38 (1994). In most cases, however, a judicial officer such as a
special master departs from previously decided issues only in the event of “new
evidence, supervening law, or a clearly erroneous decision.” Id. at 737; see also
Sullivan v. Sec'y of Health & Human Servs., No. 10-398V, 2015 WL 1404957, at *20
n.36 (Fed. Cl. Spec. Mstr. Feb. 13, 2015). After review of petitioner’s arguments as well
as the expert reports filed subsequent to the fact finding, I am not persuaded that the
prior finding of fact should be revisited. In particular, although Dr. Natanzi provided his
own review of the relevant record notations, his reanalysis of the issue did not bring any
new medical knowledge to bear on the issue. (Ex. 12, pp. 4-5.) Accordingly, I am not
convinced that the finding of fact was clearly erroneous or that new evidence warrants a
reevaluation. Petitioner has not suggested any change in the law.
However, although the Chief Special Master’s finding of fact will not be revisited,
that fact finding does not entirely resolve the factual question of onset as it relates to
Althen prong three. Because the Chief Special Master was addressing petitioner’s
Table SIRVA allegation, which has a specific onset period of 48-hours, his analysis was
limited to finding that onset of petitioner’s shoulder pain was no less than three days (or
72 hours) post-vaccination. (ECF No. 37, p. 8; 2023 WL 5844787, at *5.) In light of the
record as a whole, and having considered the parties’ arguments, I further conclude that
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the evidence preponderates in favor of finding that the onset of petitioner’s shoulder
pain occurred approximately 72 hours post-vaccination. In particular, while I agree with
the Chief Special Master that the record notation of a three-day post-vaccination onset
(Ex. 2, p. 33) is entitled to greater weight than those notations placing onset at earlier
times, there is a complete absence of any record notation placing onset any later than
three days post-vaccination.
As petitioner observes, the Federal Circuit has counseled that special masters
should not set “hard and fast deadlines” when evaluating the appropriate timeframe for
onset after vaccination. Paluck, 786 F.3d at 1384. Thus, although onset within 48
hours is required by the Vaccine Injury Table, onset in a cause-in-fact claim does not
need to occur precisely within 48 hours. Jewell v. Sec’y of Health & Human Servs., No.
16-0670V, 2017 WL 7259139, at *3 (Fed. Cl. Spec. Mstr. Aug. 4, 2017); Murray, 2022
WL 17829797, at *17; see also Pitts, 2023 WL 2770943, at *13-14. As I explained in
Murray and Pitts, the medical literature underlying SIRVA, though it does not
necessarily support a post-vaccination onset as far out as a week, does reveal that a
minority of cases of post-vaccination shoulder pain do arise beyond 48 hours. Murray,
2022 WL 17829797, at *16 (discussing articles by Martín Arias et al. & Atanasoff et al.);
Pitts, 2023 WL 2770943, at *13 (same). The same literature that was discussed in
these prior cases was also filed in this case and the record of this case does not contain
any other literature casting doubt on this conclusion.
For all of these reasons, I find that petitioner has met her preponderant burden of
proof with respect to Althen prong three, establishing that onset of symptoms of bursitis
occurring three days post-vaccination can support a causal inference of vaccination
causation.
c. Althen prong two
The second Althen prong requires proof of a logical sequence of cause and
effect, usually supported by facts derived from a petitioner’s medical records. Althen,
418 F.3d at 1278; Andreu, 569 F.3d at 1375-77; Capizzano, 440 F.3d at 1326-27;
Grant, 956 F.2d at 1147-48. Medical records are generally viewed as particularly
trustworthy evidence. Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525,
1528 (Fed. Cir. 1993). However, medical records and/or statements of a treating
physician’s views do not per se bind the special master. See § 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) (“[T]here is nothing . . . that
mandates that the testimony of a treating physician is sacrosanct—that it must be
accepted in its entirety and cannot be rebutted.”). The special master is required to
consider all the relevant evidence of record, draw plausible inferences, and articulate a
rational basis for the decision. Winkler, 88 F.4th at 963 (citing Hines, 940 F.2d at 1528).
There is no dispute that petitioner experienced a new onset of shoulder pain
shortly after her vaccination. Additionally, there is no dispute that petitioner’s surgical
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findings ultimately included a finding of bursitis, potentially consistent with petitioner’s
preponderantly supported theory of causation under Althen prong one. Furthermore, I
have concluded under Althen prong three that the timing of onset is appropriate to infer
vaccine causation. While not dispositive, petitioner’s satisfaction of Althen prongs one
and three is probative with respect to Althen prong two. Capizzano, 440 F.3d at 1326-
27 (explaining that the second Althen prong “is not without meaning,” but finding that
evidence pertaining to Althen prongs one and three can be considered under Althen
prong two). The parties present three issues with respect to Althen prong two: (1)
whether the treating physician’s notations support or reject the causal relationship
proposed by petitioner; (2) whether calcific tendinitis is a more likely explanation for
petitioner’s symptoms; and (3) whether Dr. Natanzi’s identification of post-vaccination
bursitis was reliably reached.
As the parties’ briefing makes clear, both parties can cite to treating physician
statements that seem to support their respective positions. Both Dr. Lavender and Dr.
Lineman initially supported the thinking that petitioner’s pain complaints were causally
related to her flu vaccination. (Ex. 2, pp. 31, 34.) However, as petitioner’s pain failed to
resolve over time, Dr. Lineman instead treated vaccine causation as mutually exclusive
of a musculoskeletal etiology. (Id. at 27, 29, 31.) Because petitioner had a
longstanding treatment history with her primary care providers, Drs. Lavender and
Lineman were well positioned to initially recognize the fact that petitioner’s post-
vaccination complaints were new complaints that could be associated with the
vaccination. E.g., Nuttall v. Sec’y of Health & Human Servs., 122 Fed. Cl. 821, 832
(2015) (explaining that the weight accorded to treating physician opinions is due to the
fact that they “observed the patient as the condition unfolded”), aff’d 640 F. App’x. 996
(Fed. Cir. 2016). Nonetheless, the views of treating physicians must be weighed
against other evidence in the record and their conclusions are “only as trustworthy as
the reasonableness of their suppositions or bases.” E.g., Garner v. Sec’y of Health &
Human Servs., No. 15-063V, 2017 WL 1713184, at *11 (Fed. Cl. Spec. Mstr. Mar. 24,
2017), mot. rev. denied, 133 Fed. Cl. 140 (2017). In that regard, Dr. Lineman’s later
expressed skepticism is based on an assumption that is inconsistent with petitioner’s
preponderant showing under Althen prong one. That is, contrary to what Dr. Lineman
assumed, petitioner has demonstrated that musculoskeletal shoulder pain can be
causally related to vaccination. Accordingly, I conclude that this aspect of Dr.
Lineman’s view is entitled to less weight. But in any event, a treating physician’s
opinions are not dispositive. Ultimately, a petitioner may support a cause-in-fact claim
through either medical records or expert medical opinion. § 300aa-13(a).
However, as respondent notes, I have previously addressed at greater length
how the condition of calcific tendinitis, which is not a vaccine caused condition, can
result in a clinical presentation that resembles SIRVA. Molina, 2024 WL 4223393, at
*11-12. Thus, this condition warrants careful consideration as a potential alternative
cause of injury. E.g., Winkler, 88 F.4th at 963. In this case, the issue represents a close
call. Respondent is correct to observe that calcific tendinitis was a diagnostic
consideration throughout much of petitioner’s treatment history from the time of her very
first x-ray. (E.g., Ex. 3, p. 19; Ex. 2, pp. 29-30.) Indeed, calcific tendinitis was her initial
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diagnosis when she eventually sought orthopedic care. (Ex. 5, p. 34.) Yet, respondent
has not adequately grappled with the significance of petitioner’s ultimate surgical
findings.
The specific calcium deposits initially suspected based on petitioner’s initial x-ray
imaging were not later confirmed by her subsequent imaging. (Ex. 5, p. 34.) However,
when petitioner eventually underwent MRI imaging on December 28, 2019, her findings
included bursal sided tearing of the distal infraspinatus tendon which included a newly
detected hypointense focus along the insertion that “may represent a focus of calcific
tendinopathy.” (Ex. 6, p. 35 (emphasis added).) As a result, Dr. Voloshin included
calcific tendinitis among the surgical indications (Ex. 7, p. 59), and explicitly included
“debridement of the calcium deposit” among the recommended surgical procedures
(Id.). Given this, it is highly significant that Dr. Voloshin’s description of petitioner’s
surgery states that “[o]n the bursal side with a spinal needle, the rotator cuff was
thoroughly inspected. There was no evidence of calcium deposit.” (Id. at 60.) After
petitioner’s surgery, her orthopedic follow up encounters make no mention of calcific
tendinitis. (See Exs. 10-11.)
Dr. Abrams suggests the surgical findings are not dispositive for two reasons.
(Ex. C, pp. 1-2.) First, the deposits may have been resorpted prior to the surgery. (Id.
at 2.) Second, the deposits should not necessarily be expected to be visible at the
surface. (Id. at 1.) Regarding the first point, petitioner reasonably suggests that even if
the deposit(s) had resorpted, one would still expect to see residual effects. (ECF No.
55, p. 3.) While the literature filed by Dr. Abrams indicates that resorpted calcium
deposits do not result in tendon sequela, it indicates that the process does result in
either granulation or scarring of the tissue. (Darrieutort-Laffite et al., supra, at Ex. A,
Tab 1, p. 5.) In that regard, Dr. Voloshin did not simply identify an absence of calcium
deposits but noted “no evidence of” calcium deposits. (Ex. 7, p. 60.) Regarding the
second point, Dr. Abrams ultimately admitted that Dr. Voloshin’s report does indicate
that the “inside” of the tendon was accessed to inspect for calcium deposits. (Ex. C, p.
1.) This leaves Dr. Abrams with only the potential explanation that “it is easy to miss
small to medium size lesions.” (Id.) However, Dr. Voloshin included possible calcific
tendinitis in the indications for surgery and as a result documented that “the rotator cuff
was thoroughly inspected” for calcium deposits. (Ex. 7, p. 60.) Absent a more concrete
reason for suspecting a lesion may have been missed, Dr. Voloshin’s in-person
inspection of the rotator cuff is the best evidence of what shoulder pathology was
actually present. Accord Lang v. Sec’y of Health & Human Servs., No. 17-995V, 2020
WL 7873272, at *14 (Fed. Cl. Spec. Mstr. Dec. 11, 2020) (crediting surgical findings
based on in person observation from the treating orthopedic surgeon over the
competing assessment of respondent’s expert).
Therefore, considering the record as a whole, I find that the evidence does not
preponderate in favor of a finding that calcific tendinitis explains petitioner’s condition.
Even if calcium deposits were present on earlier imaging, Dr. Abrams does not dispute
that asymptomatic calcium deposits may exist. (Ex. A, p. 8.) Dr. Abrams doubts the
likelihood of asymptomatic deposits, specifically placing the incidences of asymptomatic
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calcific tendinitis at merely 2.7% (Id.); however, this figure understates the potential for
incidental calcium deposits based on the literature accompanying Dr. Abrams’s report.
While Kim et al. includes the 2.7% figure cited by Dr. Abrams as a lower threshold, that
article states that up to 20% of patients with calcific tendinitis are asymptomatic. (Min-
Su Kim et al., Diagnosis and Treatment of Calcific Tendinitis of the Shoulder, 23 CLINICS
SHOULDER & ELBOW 210 (2020) (Ex. A, Tab 3, p. 2).) Moreover, only 35-45% of patients
with inadvertently discovered calcium deposits go on to develop symptoms. (Id. at 2-3.)
An article by McLaughlin states that calcium deposits detected by radiology are
asymptomatic “almost as frequently” as they are accompanied by symptoms.
(McLaughlin, supra, at Ex. A, Tab 2, p. 4.)
Having concluded that calcific tendinitis does not preponderantly explain
petitioner’s symptoms, there is little basis to favor Dr. Abrams’s opinion over that of Dr.
Natanzi. Respondent is especially critical of Dr. Natanzi for relying on the presence of
bursitis during petitioner’s surgery, stressing that the surgery was nearly two years after
vaccination. (ECF No. 54, pp. 8-9, 14-15.) However, respondent’s criticism is based at
least in part on his assertion that the bursitis is otherwise explained by a prior history of
calcific tendinitis. (Id. at 9.) While petitioner did have a long clinical course leading up
to her surgery, Dr. Natanzi observed that petitioner had no prior documented history of
shoulder pain or dysfunction prior to vaccination and initially developed signs of
subacromial impingement shortly after vaccination. (Ex. 12, p. 4 (citing Ex. 4, p. 20; Ex.
2, p. 31; Ex. 5, p. 54).) Respondent finds it significant that petitioner’s earlier December
28, 2019 MRI had no documented finding of bursitis (ECF No. 54, p. 9 (citing Ex. 6, p.
35), and I agree this point appears concerning; however, respondent’s argument that
this rebuts Dr. Natanzi’s opinion is not ultimately supported by any medical opinion.
Although this observation is potentially consistent with Dr. Abrams’s opinion that calcific
tendinitis is the best explanation for petitioner’s clinical presentation, Dr. Abrams did not
specifically opine on the significance (if any) of petitioner’s prior MRI. (See Exs. A, C.)
Absent the presence of calcific tendinitis as an explanation for a later development of
bursitis, respondent has not otherwise explained why petitioner’s undisputed buritis, as
uncovered as a result of her surgery, should not be correlated to her clinical
presentation, which places the onset of her shoulder pain and dysfunction in the
immediate post-vaccination period. Although prior experience with SIRVA indicates that
petitioner’s often have MRI evidence of bursitis, neither party has pointed to any
evidence indicating the sensitivity of MRI for bursitis.
For all of these reasons, I find that petitioner has met her preponderant burden of
proof with respect to Althen prong two.
d. Factor unrelated to vaccination
Once a petitioner has met her initial burden of proof, respondent may still
demonstrate that the injury was nonetheless caused by a factor unrelated to
vaccination. § 300aa-13(a)(1)(B); Deribeaux v. Sec’y of Health & Human Servs., 717
F.3d 1363, 1367 (Fed. Cir. 2013). Here, respondent asserts that petitioner’s condition is
explained by calcific tendinitis. While calcific tendinitis can cause symptoms consistent
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with petitioner’s presentation, it is not a more likely than not cause of petitioner’s
condition for the reasons discussed above.
VII. Conclusion
After weighing the evidence of record within the context of this program, I find by
preponderant evidence that petitioner suffered bursitis and related shoulder dysfunction
caused-in-fact by the flu vaccination she received on October 11, 2018. Accordingly,
petitioner is entitled to compensation. A separate damages order will be issued.
IT IS SO ORDERED.
s/Daniel T. Horner
Daniel T. Horner
Special Master
19

================================================================================
DOCUMENT 3: USCOURTS-cofc-1_20-vv-01340-2
Date issued/filed: 2025-12-02
Pages: 5
Docket text: PUBLIC DECISION (Originally filed: 11/05/2025) regarding 62 DECISION Stipulation/Proffer. Signed by Special Master Daniel T. Horner. (cd) Service on parties made.
--------------------------------------------------------------------------------
Case 1:20-vv-01340-UNJ Document 66 Filed 12/02/25 Page 1 of 5
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1340V
Filed: November 5, 2025
TERESA MAZZA, Special Master Horner
Petitioner,
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for petitioner.
Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for respondent.
DECISION AWARDING DAMAGES1
On October 7, 2020, petitioner, Teresa Mazza, filed a petition for compensation
under the National Vaccine Injury Compensation Program, 42 U.S.C. § 300aa-10, et
seq.2 (the “Vaccine Act”). (ECF No. 1.) Petitioner alleged that she suffered a right
shoulder injury as a result of an influenza (“flu”) vaccination she received on October 11,
2018. (Id.)
On September 10, 2025, a ruling on entitlement was issued, finding petitioner
entitled to compensation for bursitis and related shoulder dysfunction caused-in-fact by
her flu vaccination. (ECF No. 56.) On November 5, 2025, respondent filed a proffer on
award of compensation (“Proffer”) indicating petitioner should be awarded $115,373.00,
representing $110,000.00 for pain and suffering and $5,373.00 for past unreimbursable
expenses. (ECF No. 60.) 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.
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 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755.

Case 1:20-vv-01340-UNJ Document 66 Filed 12/02/25 Page 2 of 5
Pursuant to the terms stated in the attached Proffer, I award petitioner a lump
sum payment of $115,373.00, representing $110,000.00 in compensation for pain
and suffering and $5,373.00 in compensation for past unreimbursable expenses,
to be paid through an ACH deposit to petitioner’s counsel’s IOLTA account for
prompt disbursement to petitioner. This amount represents compensation for all
damages that would be available under § 15(a).
The clerk of the court is directed to enter judgment in accordance with this
decision.3
IT IS SO ORDERED.
s/Daniel T. Horner
Daniel T. Horner
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-01340-UNJ Document 66 Filed 12/02/25 Page 3 of 5
IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
TERESA MAZZA,
Petitioner,
v. No. 20-1340V
Special Master Daniel T. Horner
SECRETARY OF HEALTH AND ECF
HUMAN SERVICES,
Respondent.
PROFFER ON AWARD OF COMPENSATION1
On November 7, 2020, Teresa Mazza (petitioner) filed a petition for compensation under
the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to -34, as amended
(Act). Petitioner alleges that she received an influenza vaccination on October 11, 2018, and
thereafter suffered from a shoulder injury related to vaccine administration (SIRVA). See
Petition. On June 14, 2022, respondent filed his Vaccine Rule 4(c) report, concluding that this
case is not appropriate for compensation under the terms of the Act. ECF No. 30.
Notwithstanding, on September 10, 2025, the Special Master issued a Ruling on Entitlement,
finding petitioner entitled to compensation. ECF No. 56.
I. Items of Compensation
Based upon the evidence of record, respondent proffers that petitioner should be awarded
the following:
1 This Proffer does not include attorneys’ fees and costs, which the parties intend to address after
the damages decision is issued.

Case 1:20-vv-01340-UNJ Document 66 Filed 12/02/25 Page 4 of 5
A. Pain and Suffering
Respondent proffers that petitioner should be awarded $110,000.00 in pain and suffering.
See 42 U.S.C. § 300aa-15(a)(4). Petitioner agrees.
B. Past Unreimbursable Expenses
Evidence supplied by petitioner documents that she incurred past unreimbursable
expenses related to her alleged vaccine-related injury. Respondent proffers that petitioner should
be awarded past unreimbursable expenses in the amount of $5,373.00. See 42 U.S.C. § 300aa-
15(a)(1)(B). Petitioner agrees.
These amounts represent all elements of compensation to which petitioner is entitled
under 42 U.S.C. § 300aa-15(a). Petitioner agrees.
II. Form of the Award
The parties recommend that compensation provided to petitioner should be made through
a lump sum payment, as described below, and request that the Special Master’s decision and the
Court’s judgment award the following:2
A lump sum payment of $115,373.00 to be paid through an ACH deposit to petitioner’s
counsel’s IOLTA account for prompt disbursement to petitioner, Teresa Mazza.
Petitioner is a competent adult. Proof of guardianship is not required in this case.
Respectfully submitted,
BRETT A. SHUMATE
Assistant Attorney General
C. SALVATORE D’ALESSIO
Director
Torts Branch, Civil Division
2 Should petitioner die prior to entry of judgment, respondent would oppose any award for
future medical expenses, future lost earnings, and future pain and suffering, and the parties
reserve the right to move the Court for appropriate relief.
2

Case 1:20-vv-01340-UNJ Document 66 Filed 12/02/25 Page 5 of 5
HEATHER L. PEARLMAN
Deputy Director
Torts Branch, Civil Division
VORIS E. JOHNSON, JR.
Assistant Director
Torts Branch, Civil Division
s/ RYAN D. PYLES
RYAN D. PYLES
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) 616-9847
ryan.pyles@usdoj.gov
Dated: November 5, 2025
3

================================================================================
DOCUMENT 4: USCOURTS-cofc-1_20-vv-01340-cl-extra-11212520
Date issued/filed: 2025-12-02
Pages: 1
Docket text: Supplementary opinion from CourtListener cluster 10745935
--------------------------------------------------------------------------------
    In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                            No. 20-1340V
                                      Filed: November 5, 2025


    TERESA MAZZA,                                               Special Master Horner

                          Petitioner,
    v.

    SECRETARY OF HEALTH AND
    HUMAN SERVICES,

                         Respondent.


Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for petitioner.
Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for respondent.

                                 DECISION AWARDING DAMAGES1

       On October 7, 2020, petitioner, Teresa Mazza, filed a petition for compensation
under the National Vaccine Injury Compensation Program, 42 U.S.C. § 300aa-10, et
seq.2 (the “Vaccine Act”). (ECF No. 1.) Petitioner alleged that she suffered a right
shoulder injury as a result of an influenza (“flu”) vaccination she received on October 11,
2018. (Id.)

        On September 10, 2025, a ruling on entitlement was issued, finding petitioner
entitled to compensation for bursitis and related shoulder dysfunction caused-in-fact by
her flu vaccination. (ECF No. 56.) On November 5, 2025, respondent filed a proffer on
award of compensation (“Proffer”) indicating petitioner should be awarded $115,373.00,
representing $110,000.00 for pain and suffering and $5,373.00 for past unreimbursable
expenses. (ECF No. 60.) 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.

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
    National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755.
       Pursuant to the terms stated in the attached Proffer, I award petitioner a lump
sum payment of $115,373.00, representing $110,000.00 in compensation for pain
and suffering and $5,373.00 in compensation for past unreimbursable expenses,
to be paid through an ACH deposit to petitioner’s counsel’s IOLTA account for
prompt disbursement to petitioner. This amount represents compensation for all
damages that would be available under § 15(a).

       The clerk of the court is directed to enter judgment in accordance with this
decision.3


IT IS SO ORDERED.


                                                         s/Daniel T. Horner
                                                         Daniel T. Horner
                                                         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
                 IN THE UNITED STATES COURT OF FEDERAL CLAIMS
                           OFFICE OF SPECIAL MASTERS


TERESA MAZZA,

                       Petitioner,

v.                                                    No. 20-1340V
                                                      Special Master Daniel T. Horner
SECRETARY OF HEALTH AND                               ECF
HUMAN SERVICES,

                       Respondent.


                      PROFFER ON AWARD OF COMPENSATION1

       On November 7, 2020, Teresa Mazza (petitioner) filed a petition for compensation under

the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to -34, as amended

(Act). Petitioner alleges that she received an influenza vaccination on October 11, 2018, and

thereafter suffered from a shoulder injury related to vaccine administration (SIRVA). See

Petition. On June 14, 2022, respondent filed his Vaccine Rule 4(c) report, concluding that this

case is not appropriate for compensation under the terms of the Act. ECF No. 30.

Notwithstanding, on September 10, 2025, the Special Master issued a Ruling on Entitlement,

finding petitioner entitled to compensation. ECF No. 56.

I.     Items of Compensation

       Based upon the evidence of record, respondent proffers that petitioner should be awarded

the following:




1
  This Proffer does not include attorneys’ fees and costs, which the parties intend to address after
the damages decision is issued.
       A.      Pain and Suffering

       Respondent proffers that petitioner should be awarded $110,000.00 in pain and suffering.

See 42 U.S.C. § 300aa-15(a)(4). Petitioner agrees.

       B.      Past Unreimbursable Expenses

       Evidence supplied by petitioner documents that she incurred past unreimbursable

expenses related to her alleged vaccine-related injury. Respondent proffers that petitioner should

be awarded past unreimbursable expenses in the amount of $5,373.00. See 42 U.S.C. § 300aa-

15(a)(1)(B). Petitioner agrees.

       These amounts represent all elements of compensation to which petitioner is entitled

under 42 U.S.C. § 300aa-15(a). Petitioner agrees.

II.    Form of the Award

       The parties recommend that compensation provided to petitioner should be made through

a lump sum payment, as described below, and request that the Special Master’s decision and the

Court’s judgment award the following:2

       A lump sum payment of $115,373.00 to be paid through an ACH deposit to petitioner’s
       counsel’s IOLTA account for prompt disbursement to petitioner, Teresa Mazza.

       Petitioner is a competent adult. Proof of guardianship is not required in this case.

                                                     Respectfully submitted,

                                                     BRETT A. SHUMATE
                                                     Assistant Attorney General

                                                     C. SALVATORE D’ALESSIO
                                                     Director
                                                     Torts Branch, Civil Division



2
  Should petitioner die prior to entry of judgment, respondent would oppose any award for
future medical expenses, future lost earnings, and future pain and suffering, and the parties
reserve the right to move the Court for appropriate relief.

                                                 2
                              HEATHER L. PEARLMAN
                              Deputy Director
                              Torts Branch, Civil Division

                              VORIS E. JOHNSON, JR.
                              Assistant Director
                              Torts Branch, Civil Division

                              s/ RYAN D. PYLES
                              RYAN D. PYLES
                              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) 616-9847
                              ryan.pyles@usdoj.gov

Dated: November 5, 2025




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