VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_20-vv-01919
Package ID: USCOURTS-cofc-1_20-vv-01919
Petitioner: JAMES PATTERSON
Filed: 2020-12-21
Decided: 2026-02-17
Vaccine: influenza
Vaccination date: 2019-11-19
Condition: bilateral shoulder pathology
Outcome: entitlement_granted_pending_damages
Award amount USD: 

AI-assisted case summary:
James Patterson, born in 1963, received an influenza vaccine in his left arm and a hepatitis A vaccine in his right arm on November 19, 2019. He filed a petition alleging bilateral shoulder injuries, initially claiming Table SIRVA (Shoulder Injury Related to Vaccine Administration) or significant aggravation of pre-existing conditions. The initial ruling confirmed the vaccines were administered in separate arms. Subsequent expert reports and medical records were reviewed. The court found that while Patterson had pre-existing shoulder pathology, including prior dislocations and pain, the vaccinations caused a significant aggravation of this condition, specifically leading to bursitis and increased pain. The court determined that the injury met the severity requirement of lasting more than six months, despite a treatment gap during the COVID-19 pandemic. Entitlement to compensation for a significant aggravation of bilateral shoulder pathology caused by the vaccinations was granted, with a separate damages order to follow.

Theory of causation field:
Off-Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_20-vv-01919-0
Date issued/filed: 2023-11-02
Pages: 10
Docket text: PUBLIC ORDER/RULING (Originally filed: 10/02/2023) regarding 31 Findings of Fact & Conclusions of Law, Scheduling Order. Signed by Chief Special Master Brian H. Corcoran. (tlf) Service on parties made.
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Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 1 of 10
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1919V
JAMES PATTERSON, Chief Special Master Corcoran
Petitioner,
v. Filed: October 2, 2023
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leah VaSahnja Durant, Law Offices of Leah V. Durant, PLLC, Washington, DC, for
Petitioner.
Rachelle Bishop, U.S. Department of Justice, Washington, DC, for Respondent.
FINDINGS OF FACT1
On December 21, 2020, James Patterson filed a petition for compensation under
the National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that on November 19, 2019, he received an influenza
(“flu”) vaccine in his left arm and a hepatitis A (“hep A”) vaccine in his right arm – both
covered vaccines in the Program – and thereafter sustained two shoulder injuries related
to vaccine administration (“SIRVAs”), or in the alternative, the significant aggravation of
preexisting injuries. Petition, ECF No. 1; Amended Petition, ECF No. 19. The case was
assigned to the Special Processing Unit (“SPU”) of the Office of Special Masters.
1 Because this 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 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-01919-UNJ Document 32 Filed 11/02/23 Page 2 of 10
For the reasons discussed below, I find that the hep A vaccine was most likely
administered in Petitioner’s right arm, as alleged (with it undisputed the flu vaccine was
administered in his left arm). But there remain some other fact matters to resolve, and
certain aspects of the case, as discussed herein, suggest exploration of settlement would
be wise.
I. Relevant Procedural History
Petitioner filed the supporting medical records and his sworn declaration in
November 2021.3 Exs. 1-10, ECF No. 12. The case was assigned to SPU in February
2022. ECF No. 15. In June 2022, Petitioner filed additional medical records and his wife’s
sworn declaration. Exs. 11 – 13, ECF No. 20.4
On June 26, 2023, Respondent filed his Rule 4(c) Report opposing compensation
for a Table and/or off-Table claim for several reasons, including that the
contemporaneous medical record indicated that the hep A vaccine had been administered
in Petitioner’s left deltoid. Rule 4(c) Report at 10 – 17. The situs issue 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.
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
3 While Petitioner and his wife’s statements (Exs. 10, 13) are not notarized, they are signed under penalty
of perjury pursuant to 28 U.S.C.A. § 1746.
4 Petitioner did not include these pre-vaccination medical providers on his PAR Questionnaire, ECF No. 13.
2

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 3 of 10
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
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
3

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 4 of 10
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).
III. Finding of Fact
I have reviewed the record to include all medical records, affidavits,
documentation, briefing, and additional evidence filed. Summarized below is the evidence
most pertinent to my factual finding regarding the situs dispute (as well as my preliminary
reaction to other issues in the case).
• Petitioner was born in 1963. He went to the Carilion Clinic for primary care
including the management of obesity, kidney disease, and hypertension. See, e.g.,
Ex. 6 at 40-43.
• From February 27 – March 6, 2019, Petitioner attended five treatment sessions at
the Wilson Chiropractic Clinic for low back and neck pain. Ex. 11.
• On October 1, 2019, Petitioner presented to Balance Wellspace Integrative Care
to address chronic pain in his bilateral shoulders, neck, low back, and right knee.
He reported dislocating both shoulders while playing college football and rugby 30
years earlier, and receiving chiropractic treatment (for his low back and neck see
above) following a motor vehicle accident in January 2019.5 The exam findings
included bilateral shoulder tenderness, muscle tightness, and reduced range of
motion. Ex. 12 at 2 – 26, 31 – 33. X-rays found degenerative disease in both
shoulders, particularly in the AC joint space. Id. at 45 – 46.6 He was assessed with
bilateral shoulder pain, back pain, right knee pain, myalgia, cervicalgia, segmental
and somatic dysfunction. Id. at 32, 34.
• Petitioner returned to Balance Wellspace for chiropractic manipulation, electronic
muscle stimulation, and stretching – without any documented improvement in
symptoms – on November 7, 12, and 18, 2019. Ex. 12 at 35 – 40.
• On November 19, 2019, Petitioner presented to his primary care physician for his
annual evaluation. Ex. 2 at 40-48. The physician recorded, in the context of
discussing Petitioner’s increasing obesity: “His activity has been limited by some
joint and muscle pains. He is working with a chiropractor and physical therapist on
5 No contemporaneous documentation, such as emergency room or urgent care encounters, of the motor
vehicle accident have been filed.
6 Additional imaging was taken of the cervical and lumbar spine, and the right knee. Id. at 43-44, 47.
4

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 5 of 10
this presently.” Id. at 41.7 The review of systems and exam do not address the
shoulders or the musculoskeletal system. Id. at 43-44. The physician ordered flu
and hep A vaccines. Ex. 2 at 41, 48. A nurse administered both vaccines – both in
Petitioner’s left deltoid, according to the electronic medical record. Id. at 47. Of
note, the vaccine administration records were “never marked as reviewed.” Id.
(emphasis added).
• On November 20, 2019, Petitioner returned to Balance Wellspace for his fourth
treatment session. The record does not reference the previous day’s vaccinations
or any change in his condition. Ex. 12 at 41-42.
• Twenty (20) days post-vaccination, on December 9, 2019, Petitioner returned to
his primary care practice. Ex. 2 at 29-39. The evaluation was conducted by a
resident, then reviewed by his regular physician. Id. at 29. Petitioner reported
bilateral shoulder pain which “started after [he] received hep A and flu vaccines in
both deltoids about 1 month ago.” Id. at 31 (emphasis added). He disclosed a
history of shoulder dislocations. Id. He had tried conservative measures but could
not sleep at night. Id. The physical exam findings included slightly increased
hypertrophy on the left side; bilateral deltoid tenderness; pain while exhibiting full
range of motion; and pain with a Hawkins test. Id. at 34. X-ray findings were
indicative of arthritis in both shoulders. Id. at 19, 21. The resident’s differential
diagnosis included rotator cuff tear(s), bursitis, and muscle soreness and spasms
due to the vaccinations. Id. There was no evidence of frozen shoulder or radicular
symptoms. Id. Petitioner was prescribed Flexeril (cyclobenzaprine); cautioned
against NSAIDs in light of his kidney disease; and instructed on stretches. Id.
• On December 10, 2019, the primary care resident advised: “It is possible that both
vaccines were given too superiorly and caused a bursitis.” Ex. 9 at 38
(emphasis added). She prescribed oral prednisone. Id. at 41.
• On December 18, 2019, the primary care nurse documented Petitioner’s report of
ongoing bilateral shoulder pain. Ex. 9 at 29. The nurse consulted with the resident,
who suggested another appointment. Id.
• During a December 24, 2019, appointment, the primary care physician recorded
Petitioner’s history of an “acute onset of bilateral shoulder pain… which he
temporally attribute[d]… to receiv[ing] bilateral shots at his visit on November 19.”
7 As noted below, Petitioner has not conclusively addressed the potential for outstanding physical therapy
records.
5

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 6 of 10
Ex. 2 at 14 (emphasis added). The pain had been quite severe but was treated
effectively with prednisone. Id. He was concerned about taking NSAIDs long-term
in light of his kidney disease. Id. at 14-15. On exam, Petitioner was unable to raise
either arm above 90 degrees, and he was “obviously in significant pain.” Id. at 18.
The physician prescribed Mobic (meloxicam) and planned an MRI of the right
shoulder (noted to be Petitioner’s dominant side) to guide further treatment. Id.
• On December 30, 2019, at the Carilion Clinic – Roanoke Memorial Hospital,
Petitioner underwent an MRI of the right shoulder, which found: “1. moderate AC
osteoarthrosis with undersurface osteophytes which could contribute to rotator cuff
impingement; 2. mild subacromial bursitis; 3. mild supraspinatus bursal surface
tendon fraying but no evidence of a full-thickness rotator cuff tendon tear; 4.
superior glenoid labral tear.” Ex. 2 at 12.
• At a January 28, 2020, initial evaluation, an orthopedist recorded Petitioner’s
history of bilateral shoulder pain beginning within 48 hours of “bilateral
vaccinations” which were administered on 11/19/2019. Ex. 5 at 10 (emphasis
added). Petitioner disclaimed any connection to his pre-vaccination chronic pain
and chiropractic treatment. Id. He “wonder[ed] if his problem could be a vaccine-
related injury.” Id. After reviewing an MRI report and conducting an exam, the
orthopedist offered a differential diagnosis of subacromial bursitis, Parsonage-
Turner syndrome, and/or “SILVA.” Id. at 11-12. He provided bilateral bursa steroid
injections and recommended physical therapy (“PT”). Id. at 12.8
• On March 3, 2020, upon presenting to a new primary care practice, Petitioner
reported “a bad reaction to vaccines,” and the development of bilateral shoulder
bursitis. Ex. 8 at 3-5.
• At the March 18, 2020, PT initial evaluation at Lucas Therapies, Petitioner reported
“bilateral shoulder dysfunction after shots for immunization and the flu… on
11/19/2019.” Ex. 3 at 11 (emphasis added). He “awoke 48 hours later with
complete inability to move his shoulders.” Id. He acknowledged prior shoulder
dislocations in association with football and rugby, and “no other contributory past
medical [or] past surgical history.” Id. After reviewing the treatment course to date
and conducting a physical exam, the therapist assessed bilateral bursitis; right-
8 Petitioner followed up with the orthopedist on March 12 and May 4, 2020. Ex. 5 at 2-8. After a thirteen-
month gap in any medical treatment, he returned to the orthopedist on June 14 and July 1, 2021. Ex. 7 at
1-11. These records do not supplement or contradict the evidence summarized above, with regard to situs
– although they are relevant to additional issues in the case, as discussed below.
6

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 7 of 10
sided bicipital tendinitis; disuse atrophy; scapular instability; and possible
underlying cuff issues. Id. at 11 – 12 (noting that the assessment was incomplete
and lacked review of his MRI). The therapist recommended formal PT “once a
week for several weeks to develop a strengthening program to accomplish
[Petitioner’s] goals of return to the gym and full use of his shoulders.” Id. at 12.9
• Petitioner and his wife both attest that the flu vaccine was administered in his left
arm, followed by the hep A vaccine in his right arm. Exs. 10, 13.
Respondent argues that Petitioner cannot establish a right-sided hep A vaccine
administration because the contemporaneous record indicates the left deltoid. Rule 4(c)
Report at 10, citing Ex. 2 at 47-48. A contrary finding, Respondent contends, cannot be
made on Petitioner’s claims alone, and his wife’s statements about the topic should not
be afforded probative value. Rule 4(c) at 10 and n. 8.
“Medical records, in general, warrant consideration as trustworthy evidence . . . [as
they] contain information supplied to or by health professionals to facilitate diagnosis and
treatment of medical conditions.” Cucuras, 993 F.2d at 1528. But based upon my
experience resolving SPU SIRVA cases (over 1,300 cases since my appointment as
Chief Special Master) as well as additional SIRVA cases handled in chambers, it is not
unusual for the information regarding site of vaccination in computerized systems to be
incorrect. Many of these systems use a “dropdown” menu to enter information, and the
relevant fields are often not updated each time a separate vaccine is administered to a
different individual. See, e.g., Mezzacapo v. Sec’y of Health & Hum. Servs., No. 18-
1977V, 2021 WL 1940435, at *6 (Fed. Cl. Spec. Mstr. Apr. 19, 2021); Desai v. Sec’y of
Health & Hum. Servs., No 14-0811V, 2020 WL 4919777, at *14 (Fed. Cl. Spec. Mstr. July
30, 2020); Rodgers v. Sec’y of Health & Hum. Servs., No. 18-0559V, 2020 WL 1870268,
at *5 (Fed. Cl. Spec. Mstr. Mar. 11, 2020); Stoliker v. Sec’y of Health & Hum Servs., No.
17-0990V, 2018 WL 6718629, at *4 (Fed. Cl. Spec. Mstr. Nov. 9, 2018). This case
similarly involves computerized vaccine administration records, which would be
susceptible to such errors. Additionally in past cases, medical providers have attested to
a practice of utilizing both shoulders when administering more than one vaccine. Rodgers,
2020 WL 1870268, at *4-5.
Here, Petitioner received two vaccinations on the same day – and he recalled
receiving one in each arm. Ex. 10 at ¶ 2. The sole record to contradict this contention is
the vaccine administration record. But although it indicates that the left deltoid was utilized
9 While Petitioner returned for a second PT session on March 25, 2020, the record does not include
additional information relevant to my situs determination.
7

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 8 of 10
twice on the same day, this document was “never reviewed” by the primary care providers
– even after encountering Petitioner for his post-vaccination complaints. Ex. 2 at 47.10
Thus, the record itself allows for the possibility that it is incorrect.
Moreover, the witness statements about onset are not without corroboration. In a
number of the contemporaneous records, Petitioner reported a history of bilateral
vaccinations beginning just 20 days later, and consistently did so to at least five different
medical providers. While these entries were based upon information provided by
Petitioner, they still deserve weight, especially since they were generated in connection
with his efforts to obtain medical care.11
Thus, the record in this case preponderates in favor of the conclusion that the hep
A vaccine was more likely than not administered in Petitioner’s right arm, as alleged.
IV. Further Analysis
A. Potentially Outstanding Records
It appears that in January 2020, an orthopedist made a typographical error
suggesting the existence of an MRI from “12/9/2010.” Ex. 5 at 12. The orthopedist went
on to review an MRI report with findings that seem very consistent with those from a
December 30, 2019, MRI report pertaining to the right shoulder. Compare Ex. 5 at 10-12;
Ex. 2 at 12. At a subsequent visit, the orthopedist recorded that he had reviewed the
December 2019 MRI. Ex. 7 at 9. But it appears that at least some MRI reports remain
unfiled, which Petitioner must address. See Rule 4(c) Report at n. 1, 4.
Petitioner must also satisfy Respondent’s renewed request for potentially
outstanding PT records. Rule 4(c) Report at n. 3. While Respondent’s previous request
for such records prompted Petitioner’s filing of Exs. 11 – 12, those medical records are of
chiropractic care, which leaves open the question of pre-vaccination PT from other
provider(s).
10 There is also no evidence that Petitioner was aware of the site notation within his primary care provider’s
electronic medical records during his active treatment course.
11 The Federal Circuit has stated that “[m]edical records, in general, warrant consideration as trustworthy
evidence . . . [as they] contain information supplied to or by health professionals to facilitate diagnosis and
treatment of medical conditions.” Cucuras, 993 F.2d at 1528 (emphasis added).
8

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 9 of 10
B. Table SIRVA Criteria
As noted above, approximately two months prior to the subject vaccinations
Petitioner began seeking chiropractic treatment for chronic bilateral shoulder pain – and
he was documented to have bilateral tenderness, reduced range of motion, and
degenerative joint disease. The prior history alone complicates Petitioner’s pursuit of
Table SIRVA claim(s), at the very least – and may require their dismissal. See also Rule
4(c) Report at 12 – 15 (raising additional arguments regarding significance of the
visualized pathology; pain beyond the shoulders; etc.). Thus, the favorable situs finding
herein does not overcome all stumbling blocks to entitlement.
C. Severity
Program compensation is limited to vaccine injuries with “residual effects or
complications of such illness, disability, or condition for more than 6 months after the
administration of the vaccine.” Section 13(a)(1)(A). It is often appropriate to resolve any
severity issue first, given that it is a threshold requirement for eligibility under the Program.
Black v. Sec’y of Health & Hum. Servs., 33 Fed. Cl. 546, 550 (1995) (reasoning that the
“potential petitioner” must not only make a prima facie case, but clear a jurisdictional
threshold, by “submitting supporting documentation which reasonably demonstrates that
a special master has jurisdiction to hear the merits of the case”), aff’d, 93 F.3d 781 (Fed.
Cir. 1996) (internal citations omitted).
In this case, after receiving the flu and hep A vaccines bilaterally on November 19,
2019, Petitioner sought treatment for new acute bilateral shoulder pain promptly
(beginning 20 days post-vaccination) and regularly (receiving prescription pain
medications, imaging, steroid injections, two PT sessions) up until May 4, 2020. That
initial treatment course spanned five and one-half months – and the documentation
thereof does not clearly indicate that Petitioner’s bilateral shoulder complaints were likely
to conclude within just two more weeks. My preliminary assessment is that Petitioner’s
alleged injuries likely cross the severity “threshold.”
Respondent emphasizes the thirteen (13) month treatment gap from May 2020 –
June 2021, during which Petitioner did not follow up with his providers via telehealth or
refill prescription pain medications (which would be more attractive, given that NSAIDs
were contraindicated due to Petitioner’s kidney disease). These observations would
indicate that any ongoing injury was self-manageable and not significantly disruptive to
Petitioner’s life – but they do not extinguish a claim on their own. At most, they go to
overall severity, which is more relevant to damages calculations.
9

Case 1:20-vv-01919-UNJ Document 32 Filed 11/02/23 Page 10 of 10
When Petitioner eventually followed up, he again reported a November 2019 onset
of bilateral shoulder pain. Ex. 7 at 13. The established orthopedist’s exam findings and
treatment recommendations appear similar to those at the prior encounters. Compare Ex.
5 at 2 – 10; and Ex. 7 – 11. However, the orthopedist did not expressly endorse the onset
provided by Petitioner or attribute his ongoing complaints to the vaccinations. Ex. 7 at 1
– 3, 9 – 11. The orthopedist instead noted Petitioner’s history of remote shoulder
dislocations and recent exercise resulting in biceps soreness. Id. at 9, 11. The orthopedist
also prescribed PT for “scapular dyskinesis.” Id. at 11. Thus, Petitioner’s later complaints
and objective findings are less clear based on the existing evidence – and may require a
medical opinion, which I am not inclined to authorize while the case remains in SPU.
Conclusion and Scheduling Order
For the foregoing reasons, it is more likely than not that the hep A vaccine was
administered in Petitioner’s right arm as alleged. However, his prior history complicates
both the Table SIRVA claims and a specific severity finding. These circumstances justify
a brief exploration of informal resolution for a reasonable figure. Petitioner should make
any necessary adjustments to his demand, and that should be considered by
Respondent. If the parties cannot reach a tentative settlement agreement by February
2024, the case will be transferred out of SPU.
According by no later than Friday, December 01, 2023, Petitioner shall file a
joint status report updating me on this case. The status report shall indicate
whether Respondent’s records requests have been satisfied. The status report
shall also update on the parties’ efforts to informally resolve this case and
proposing their preferred next steps.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
10

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DOCUMENT 2: USCOURTS-cofc-1_20-vv-01919-1
Date issued/filed: 2026-02-17
Pages: 25
Docket text: PUBLIC ORDER/RULING (Originally filed: 1/21/2026) regarding 50 Ruling on Entitlement. Signed by Special Master Daniel T. Horner. (ksb) Service on parties made.
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Case 1:20-vv-01919-UNJ Document 52 Filed 02/17/26 Page 1 of 25
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1919V
Filed: January 21, 2026
Special Master Horner
JAMES PATTERSON,
Petitioner,
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leah VaSahnja Durant, Law Offices of Leah V. Durant, PLLC, Washington, DC, for
petitioner.
Rachelle Bishop, U.S. Department of Justice, Washington, DC, for respondent.
RULING ON ENTITLEMENT1
On December 21, 2020, petitioner filed a petition under the National Childhood
Vaccine Injury Act (“Vaccine Act”), 42 U.S.C. § 300aa-10, et seq. (2012).2 He initially
alleged a left-side Table Injury of “SIRVA,” i.e., a shoulder injury related to vaccine
administration, resulting from influenza (“flu”) and Hepatitis A vaccinations he received
on November 19, 2019. (ECF No. 1.) Alternatively, he alleged a left shoulder injury
“caused-in-fact” or significantly aggravated by his vaccination. (Id.) However, he later
filed an amended petition alleging that the two vaccinations had been administered in
separate arms, resulting in bilateral shoulder injuries. (ECF No. 19.) In the amended
petition, petitioner asserted his bilateral shoulder injuries constituted Table SIRVAs or,
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-01919-UNJ Document 52 Filed 02/17/26 Page 2 of 25
alternatively, that he suffered bilateral significant aggravation of preexisting shoulder
issues. (Id.)
For the reasons set forth below, I conclude that petitioner is entitled to
compensation for a significant aggravation of bilateral shoulder pathology caused-in-fact
by his November 19, 2019 vaccinations.
I. Applicable Statutory Scheme
Under the National Vaccine Injury Compensation Program, compensation
awards are made to individuals who have suffered injuries after receiving vaccines. In
general, to gain an award, a petitioner must make a number of factual demonstrations,
including showing that an individual received a vaccination covered by the statute;
received it in the United States; suffered a serious, long-standing injury; and has
received no previous award or settlement on account of the injury. Finally – and the key
question in most cases under the Program – the petitioner must also establish a causal
link between the vaccination and the injury.
In some cases, the petitioner may simply demonstrate the occurrence of what
has been called a “Table Injury.” That is, it may be shown that the vaccine recipient
suffered an injury of the type enumerated in the “Vaccine Injury Table,” corresponding to
the vaccination in question, within an applicable time period following the vaccination
also specified in the Table. If so, the Table Injury is presumed to have been caused by
the vaccination, and the petitioner is automatically entitled to compensation, unless it is
affirmatively shown that the injury was caused by some factor other than the
vaccination. § 300aa-13(a)(1); § 300aa-11(c)(1)(C)(i); § 300aa-14(a).
As relevant here, the Vaccine Injury Table lists a Shoulder Injury Related to
Vaccine Administration or “SIRVA” as a compensable injury if it occurs within 48 hours
of vaccine administration. § 300aa-14(a), amended by, 42 C.F.R. § 100.3. Table Injury
cases are guided by statutory “Qualifications and aids in interpretation” (“QAIs”), which
provide a more detailed explanation of what should be considered when determining
whether a petitioner has suffered an injury listed on the Vaccine Injury Table. 42 C.F.R.
§ 100.3(c). To be considered a “Table SIRVA,” petitioner must show that his injury fits
within the following definition:
SIRVA manifests as shoulder pain and limited range of motion occurring
after the administration of a vaccine intended for intramuscular
administration in the upper arm. These symptoms are thought to occur as
a result of unintended injection of vaccine antigen or trauma from the needle
into and around the underlying bursa of the shoulder resulting in an
inflammatory reaction. SIRVA is caused by an injury to the musculoskeletal
structures of the shoulder (e.g. tendons, ligaments, bursae, etc.). SIRVA is
not a neurological injury and abnormalities on neurological examination or
nerve conduction studies (NCS) and/or electromyographic (EMG) studies
would not support SIRVA as a diagnosis . . . . A vaccine recipient shall be
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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
(iv) No other condition or abnormality is present that would explain the
patient’s symptoms (e.g. NCS/EMG or clinical evidence of
radiculopathy, brachial neuritis, mononeuropathies, or any other
neuropathy).
42 C.F.R. § 100.3(c)(10).
Alternatively, if no injury falling within the Table can be shown, the petitioner may
still demonstrate entitlement to an award by showing that the vaccine recipient’s injury
was caused-in-fact by the vaccination in question. § 300aa-13(a)(1)(A); § 300aa-
11(c)(1)(C)(ii). To so demonstrate, a petitioner must show that the vaccine was “not
only [the] but-for cause of the injury but also a substantial factor in bringing about the
injury.” Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1321 (Fed. Cir.
2010) (quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344, 1352-53
(Fed. Cir. 1999)); Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352, 1355
(Fed. Cir. 2006). In particular, a petitioner must show by preponderant evidence: (1) a
medical theory causally connecting the vaccination and the injury; (2) a logical
sequence of cause and effect showing that the vaccination was the reason for the
injury; and (3) a showing of proximate temporal relationship between vaccination and
injury in order to prove causation-in-fact. Althen v. Sec’y of Health & Human Servs.,
418 F.3d 1274, 1278 (Fed. Cir. 2005). Additionally, where a petitioner in an off-Table
case is seeking to prove that a vaccination aggravated a pre-existing injury, the
petitioner must establish the three Althen prongs along with three additional factors
described in the Loving case. See Loving v. Sec’y of Health & Human Servs., 86 Fed.
Cl. 135, 144 (2009) (combining the first three Whitecotton factors for claims regarding
aggravation of a Table injury with the three Althen factors for off-Table injury claims to
create a six-part test for off-Table aggravation claims); see also W.C. v. Sec’y of Health
& Human Servs., 704 F.3d 1352, 1357 (Fed. Cir. 2013) (applying the six-part Loving
test). The additional Loving factors require petitioners to demonstrate aggravation by
showing: (1) the vaccinee’s condition prior to the administration of the vaccine, (2) the
vaccinee’s current condition, and (3) that the vaccinee’s current condition constitutes a
“significant aggravation” of the condition prior to the vaccination. Loving, 86 Fed. Cl. at
144.
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For both Table and non-Table claims, Vaccine Program petitioners must
establish their claim by a “preponderance of the evidence.” § 300aa-13(a). That is, a
petitioner must present evidence sufficient to show “that the existence of a fact is more
probable than its nonexistence.” Moberly, 592 F.3d at 1322 n.2. Proof of medical
certainty is not required. Bunting v. Sec’y of Health & Human Servs., 931 F.2d 867,
872-73 (Fed. Cir. 1991). However, a petitioner may not receive a Vaccine Program
award based solely on his assertions; rather, the petition must be supported by either
medical records or by the opinion of a competent physician. § 300aa-13(a)(1). Once a
petitioner has established their prima facie case, the burden then shifts to respondent to
prove, also by preponderant evidence, that the alleged injury was caused by a factor
unrelated to vaccination. Althen, 418 F.3d at 1278; § 300aa-13(a)(1)(B).
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 but are empowered to determine the format for taking
evidence based on the circumstances of each case, including having the discretion to
decide cases without an evidentiary hearing. Vaccine Rule 3(b)(2); 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).
In determining entitlement to compensation, the special master is required to
consider “all [] relevant medical and scientific evidence contained in the record,”
including “any diagnosis, conclusion, medical judgment, or autopsy or coroner’s report
which is contained in the record regarding the nature, causation, and aggravation of the
petitioner’s illness, disability, injury, condition, or death,” as well as the “results of any
diagnostic or evaluative test which are contained in the record and the summaries and
conclusions.” § 300aa-13(b)(1). The special master is required to consider the entirety
of the evidentiary 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 initially assigned to the Chief Special Master for potential informal
resolution as part of the Special Processing Unit (or “SPU”) based on the allegations of
the petition. (ECF No. 15-16.) However, respondent was not willing to entertain
settlement and filed his Rule 4 report in June of 2023, recommending against
compensation. (ECF No. 30.) In addition to disputing whether petitioner could
demonstrate either Table SIRVAs or shoulder injuries caused-in-fact by his two
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vaccinations, respondent also contested a bilateral administration of the two vaccines,
as well as whether petitioner suffered at least six months of sequela. (Id. at 10-18.)
Within the SPU, the Chief Special Master issued a finding of fact, which
concluded that petitioner had received his Hepatitis A vaccine in his right arm and his flu
vaccination in his left arm.3 (ECF No. 31, p. 2.) However, because the finding of fact
did not foster settlement discussions, the case was reassigned to the undersigned for
further litigation. (ECF No. 37.)
After reassignment, both parties filed expert reports. Petitioner filed a report by
orthopedic surgeon Uma Srikumaran, M.D., and respondent filed a responsive report by
orthopedic surgeon Paul Cagle, M.D. (ECF Nos. 39-40; Exs. 16, A.) After petitioner
filed a reply by Dr. Srikumaran (ECF No. 43; Ex. 36), the parties agreed that the case
was ripe for briefing. (ECF No. 45.) Petitioner then filed a motion for a ruling on the
written record in January of 2025, which is now fully briefed. (ECF Nos. 47-49.)
In light of the above, I have determined that the parties have had a full and fair
opportunity to develop the record and that it is appropriate to rule on the existing record.
See Vaccine Rule 8(d); Vaccine Rule 3(b)(2); Kreizenbeck v. Sec’y of Health & Human
Servs., 945 F.3d 1362, 1366 (Fed. Cir. 2020) (noting that “special masters must
determine that the record is comprehensive and fully developed before ruling on the
record”). Accordingly, petitioner’s motion is now ripe for resolution.
III. Summary of Record Evidence
a. Medical Records
i. Pre-vaccination
In his motion, petitioner asserts that his medical history prior to the vaccinations
at issue was noncontributory. (ECF No. 47, p. 3.) Respondent disagrees. (ECF No.
48, pp. 2-3.) Specifically, seven weeks before the subject vaccinations, petitioner
presented to an integrative medicine specialist (“Wellspring”) on October 1, 2019, for an
initial evaluation. (Ex. 12.) At that time, petitioner reported, among other complaints, a
“bilateral shoulder pain complaint of unknown origin ongoing for years.” (Id. at 31.)
More specifically, petitioner felt his pain was related to his rotator cuff, though he was
unaware of any injury. (Id.) However, he did note a prior history of multiple shoulder
dislocations in both shoulders while playing football and rugby 30 years ago. (Id. at 6.)
He rated his pain, which was noted to be constant, as ranging from 3-5 on a 10-point
scale. (Id.) On physical exam, petitioner had reduced range of motion in both
3 I have reviewed the Chief Special Master’s finding of fact and adopt it as my own. 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).
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shoulders (based on Apley’s 1 and 2 tests) with muscle spasm trigger points affecting
multiple muscles of the neck and shoulders. (Id. at 31-32.) He was assessed as having
both cervicalgia and shoulder pain. (Id. at 32.) He returned for therapeutic exercises on
November 7, 2019, November 12, 2019, and November 18, 2019, and it was noted at
each encounter that his complaints were essentially unchanged. (Id. at 35, 37, 39.)
On November 19, 2019, petitioner presented to his primary care provider, Mark
Greenawald, M.D., for routine care, as well as vaccinations for an upcoming trip to
Nepal. (Ex. 1, pp. 1-2.) He did not report any musculoskeletal complaints, and physical
exam appears to have been cursory, though it was noted that his obesity may be
worsening and that his activity had been limited due to joint and muscle pains. (Id. at 2,
4-5.) At this encounter he was administered the Hepatitis A and flu vaccinations at
issue. (Id. at 8-9.) As found in the prior finding of fact, these vaccines were
administered one in each shoulder. (ECF No. 31.)
ii. Post-vaccination
Petitioner returned to Wellspring on November 20, 2019, the day after the subject
vaccinations. (Ex. 12, p. 41.) It was again noted that petitioner’s condition had not
changed. (Id.)
On December 9, 2019, petitioner returned to his primary care provider with a
complaint of bilateral hip and shoulder pain. (Ex. 2, p. 30.) He reported that the
shoulder pain “started after received hep A and flu vaccine in both deltoids about 1
month ago,” whereas the hip pain started “a few months ago.” (Id. at 31.) Petitioner
denied neck pain, weakness or decreased strength, but indicated that his pain
worsened with reaching and interfered with his sleep. (Id.) On physical exam,
petitioner had full range of motion in all planes for both his hips and shoulders; however,
the shoulder movement reproduced pain. He had tenderness to palpation over the
deltoids, but no tenderness or crepitus of the acromioclavicular joint and normal
glenohumeral stability. He had full strength in both shoulders, but had a positive
Hawkins test (also called a Hawkins Kennedy test), which tests for shoulder
impingement. Empty can test, which tests for rotator cuff issues, was negative. (Id. at
34.) C Reactive Protein and sedimentation rate, nonspecific inflammatory markers,
were high. (Id. at 37; see also Ex. 9, p. 38.) X-ray findings from both shoulders were
consistent with arthritis. (Ex. 2, pp. 19, 21; see also Ex. 9, p. 38.) Petitioner did not
receive a definitive diagnosis at this encounter. Buritis was considered possible given
the positive Hawkins test; however, the additional presence of hip pain raised a concern
for polymyalgia rheumatica (“PMR”). (Ex. 2, p. 30.) Petitioner was started on
prednisone. (Ex. 9, p. 38.)
Petitioner’s pain was initially “resolved completely” while he was on prednisone,
but he reported that pain in both shoulders and legs returned as of December 18, 2019.
(Ex. 2, p. 14; Ex. 9, p. 29.) He returned to his primary care provider, Dr. Greenawald,
on December 24, 2019. (Ex. 2, p. 14.) At that time, he reported that the pain “has been
quite severe” and that “temporally [he] attributes the symptoms to when he received
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bilateral shots.” (Id. at 14-15.) However, the pain was alleviated by ibuprofen. (Id. at
14.) He did not have any weakness, numbness, or symptoms radiating down his arm.
He reported being unable to lift his arms above 90 degrees. (Id.) Bilateral bursitis
continued to be questioned. (Id. at 15.) On physical exam, it was noted that petitioner
was “[o]bviously in significant pain” and Neer (a test for subacromial impingement) and
empty can tests were positive. (Id. at 18.) An MRI of the right shoulder was ordered,
with a plan to recommend bilateral steroid injections if the MRI confirmed bursitis. (Id.)
Petitioner was prescribed Meloxicam. (Id.) Petitioner underwent a right shoulder MRI
on December 30, 2019. (Id. at 12; Ex. 14, p. 5.) The impression was: (1) moderate
acromioclavicular osteoarthritis with undersurface osteophytes; (2) mild subacromial
bursitis; (3) mild supraspinatus bursal surface tendon fraying with no evidence of a full
thickness tear; and (4) a superior glenoid labral tear. (Ex. 14, p. 5.)
On January 28, 2020, petitioner followed up with an orthopedist for his bilateral
shoulder (and neck) pain. (Ex. 5, p. 10.) Petitioner reported a prior history of multiple
dislocations from a college and semi-pro football career but associated his shoulder
pain to his vaccinations, noting his shoulders to have been “nonproblematic” in the
decades since his football career. (Id.) He rated his pain as a 9 out of 10 at worst. (Id.)
Petitioner noted that he saw a chiropractor prior to vaccination, but felt his post-
vaccination symptoms were distinct. (Id.) He reported significantly decreased activity
due to shoulder pain, as well as “a fair bit of sleep disruption.” (Id.) On physical exam,
petitioner had positive Hawkins, Neer, and Obrien’s tests, bilaterally, but negative
Yergason’s and Spurling’s tests.4 (Id. at 11.) The orthopedist diagnosed bilateral
shoulder bursitis5 and administered bilateral steroid injections. (Id. at 11-12.)
Petitioner returned to the orthopedist for a re-evaluation on March 12, 2020. (Ex.
5, p. 6.) He reported that his left shoulder had improved, but that his right shoulder,
while less debilitating, remained painful. (Id.) He felt that his steroid injections may be
wearing off. (Id.) He rated his pain as a 6 out of 10 at rest and an 8 out of 10 with
activity. (Id.) His assessment continued to include bilateral bursitis with some noted
improvement in symptoms, but also now included a right-side biceps tendonitis for
which he was administered a right biceps tendon sheath injection. (Id. at 7-8.) Shortly
thereafter, petitioner presented for a physical therapy evaluation. (Ex. 3, p. 11.) He had
full range of motion of both shoulders, but he had pain with resisted internal rotation on
the right, as well as mild weakness and pain with Neer and Hawkins tests. He also had
pain with a Hawkins test on the left. (Id.) He only attended one follow up session at
which he was reportedly improved, but with some remaining weakness. (Id. at 9-10.)
4 The O’Brien’s test checks for labral tears and/or acromioclavicular issues, while the Yergason test
checks for issues affecting the biceps tendon. The Spurling test checks for cervical radiculopathy.
5 The “Assessments” for this encounter specified bursitis of both the left and right shoulders. (Ex. 5, p.
11.) However, in notes, the orthopedist stated that the “differential includes, or perhaps is a combination
of, subacromial bursitis, possible mild Parsonage-Turner syndrome, SILVA.” (Id. at 12.) Given that the
orthopedist had noted the injury to have occurred “in the setting of injection” (Id.), the reference to
“SILVA” is likely a typographical error meant to refer to “SIRVA.”
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On May 4, 2020, approximately five and a half months post-vaccination,
petitioner returned for a follow up with his orthopedist. (Ex. 5, p. 2.) The orthopedist
characterized petitioner’s condition as “bilateral shoulder pain, primarily attributable to
some combination of [SLAP] and biceps tendon symptoms, and subacromial bursitis, in
the setting of a flare after vaccination.” (Id.) Petitioner reported experiencing some
improvement following his right biceps tendon sheath injection and that his left shoulder
was “more bothersome.” (Id.) Physical exam confirmed that, although he had positive
O’Brien’s bilaterally, it was worse on the left than the right. (Id. at 3.) The orthopedist
added left shoulder biceps tendonitis to petitioner’s assessment and administered a left-
side biceps tendon sheath injection. (Id. at 3-4.) The orthopedist advised that the next
step would potentially be an arthroscopic examination, debridement, or biceps
tenodesis. (Id. at 4.)
Thereafter, petitioner did not return again for care until more than thirteen months
later, on June 14, 2021. (Ex. 7, p. 9.) Petitioner’s interval history was as follows:
Pain Level: 4/10 at rest and 7/10 with activity. Patient reports 5/10 overall
function in both of his shoulders. Pain is intermittent and is described as
being dull that does not radiate in nature. He admits to occasional
weakness in his shoulders. Patient reports he has been working his
muscles recently. He still reports soreness which is worse on the left
shoulder when compared to the right shoulder. He reports several
dislocations in the past in the left shoulder. He also reports scapular
spasms and discomfort. Patient admits to starting PT and has transitioned
to home exercises for further strengthening. Patient is interested in having
a MRI done on his left shoulder in order to plan for next steps.
Pain is worse with pushing, reaching overhead, reaching across body, and
with lifting weights. Pain is relieved with rest, ice/heat, and medication.
Symptoms have stayed around the same.
(Id.) Based on the physical exam, the orthopedist felt that petitioner was experiencing
“biceps soreness from working out recently,” left worse than right, as well as
periscapular muscle spasms of the right shoulder. (Id. at 11.) An MRI was ordered to
assess the left biceps tendon, and physical therapy was recommended for right-side
scapular dyskinesis. (Id.)
Petitioner returned on July 12, 2021, to discuss his MRI results. (Ex. 7, p. 1.)
The MRI showed
moderate to advanced [acromioclavicular] arthritis with arthrosis, anterior
labral irregularity without significant heterogeneity that may represent
chronic [SLAP] tear versus non pathologic[.] Buford complex or labral
foramen, inferolateral subacromial spurring, relatively narrow acromial
humeral interval without full-thickness tears, there is intrasubstance tearing
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of the supraspinatus and possibly a near full-thickness small tear at the very
anterior margin, also with some superior biceps tendinopathy.
(Id. at 3.) The orthopedist felt that surgery was appropriate because the magnitude of
the left-side rotator cuff tear could not be determined, but petitioner deferred surgery
and opted for a therapeutic injection instead. (Id.)
Petitioner has not had any further medical evaluations. (ECF No. 27.)
b. Affidavits
i. Petitioner
After describing his encounter for vaccination, petitioner stated that “[w]ithin 2
days my shoulders began getting really sore and on the third day I was surprised that I
couldn’t even lift them up to wash my hair in the shower.” (Ex. 10, p. 1.) The pain and
reduced mobility persisted up to the time of his encounter with Dr. Greenawald, after
which time he received temporary relief from prednisone. (Id.)
Petitioner further explained that
I had a break in visiting the doctor from May of 2020 to June of 2021. Even
though I still had pain in my shoulders, I was not able to be seen during
COVID. I was finally able to return for treatment in June of 2021. I went
back in to be seen as the pain and limited range of motion had not fully
resolved. I was getting stronger, but still not where I was prior to the
vaccinations.
(Ex. 10, p. 2.)
In a supplemental affidavit, petitioner explained that he is still symptomatic
despite having ceased formal treatment. (Ex. 38.) He stated that “[t]o this day, I
continue to suffer pain and limitations because of the injuries to both my shoulders” and
that, “[a]lthough I am not currently undergoing formal treatment for my shoulders, I
continue to do a daily home exercise program to try to relieve some of my discomfort
and mobility problems.” (Id.) He concluded that “I have reached a point of toleration
that I consider to be my new normal.” (Id.)
ii. Jeanie L. Patterson
Ms. Patterson, petitioner’s spouse, is a registered nurse. She avers that she
observed petitioner on the evening that he was vaccinated and noticed that his two
injection site band aids were higher on his shoulders than would be expected from a
proper administration. (Ex. 13, p. 1.) She further states that
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[a]fter 2 days of [petitioner] experiencing ongoing pain, I encouraged him to
go back to the primary care physician to get support and relief as I was very
concerned as to his pain and limited movement when showering, driving,
dressing, and other motions. It was apparent to me that [petitioner]’s
reduced range of motion was clearly due to the location of the injections he
had received.
(Id.)
c. Expert Opinions
Petitioner filed an expert report by orthopedic surgeon Uma Srikumaran, M.D.6
(Ex. 16.) Dr. Srikumaran acknowledges that petitioner had a prior history of bilateral
shoulder pain, but suggests that “it is important to note a change in [the] type and
severity of pain following the vaccinations.” (Id. at 7.) Prior to vaccination, petitioner’s
chiropractic records reflect a base level of constant pain between 3-5 on a 10-point
scale with no specific shoulder complaints included in his subjective reports. Only Apley
tests suggested any shoulder issues. (Id. at 7-8.) However, Dr. Srikumaran
characterizes Apley tests as measuring muscle “tightness,” rather than pain. (Id. at 8.)
Following vaccination, petitioner suffered a “drastic” change in his condition, with pain
and disability that prompted ongoing care. (Id.) Moreover, Dr. Srikumaran opines that
the post-vaccination signs and symptoms were consistent with SIRVA. (Id.)
Specifically, he stresses that petitioner had demonstrated reduction in motion following
vaccination, as well as positive impingement tests (Hawkins) from his very first post-
vaccination medical encounter. (Id.)
Dr. Srikumaran acknowledges that petitioner had pre-existing changes visible on
his MRI; however,
[t]he general, and specific theory in this case, of causation of shoulder
dysfunction related to vaccination is the initiation of inflammation directly
related to vaccine antigen being delivered to or near the bursa or synovium
6 Dr. Srikumaran received his medical degree from Johns Hopkins University School of Medicine in 2005,
before going on to complete an internship in general surgery and orthopedic surgery, as well as a
residency in orthopedic surgery, at Johns Hopkins Hospital in 2006 and 2010, respectively. (Ex. 17, p. 1.)
From there, Dr. Srikumaran completed a fellowship in shoulder surgery at Harvard in 2011. (Id.; Ex. 16,
p. 1.) He is board certified in orthopedic surgery, and he maintains an active medical license in Maryland.
(Ex. 17, p. 19.) Dr. Srikumaran currently works as the Director of the shoulder fellowship and Vice Chair-
Quality, Safety, and Service of the Department of Orthopaedic Surgery, as well as an associate professor
of orthopaedic surgery in the shoulder division, at Johns Hopkins University School of Medicine. (Id. at 1-
2.) He also maintains positions as the Medical Director at Johns Hopkins Ambulatory Surgery Center and
an attending physician at Johns Hopkins Hospital, Howard County Medical Center. (Id.) In his clinical
capacity, Dr. Srikumaran has treated approximately 10-12 patients with shoulder dysfunction following
vaccination in the last five years. (Ex. 16, p. 1.) In his research capacity, Dr. Srikumaran has authored
several publications in the field of shoulder surgery, including two articles specifically discussing SIRVA.
(Id. at 2-16; Ex. 16, p. 1.)
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of the joint. It is this inflammation which initiates pain in previously
longstanding, chronic degenerative conditions.
(Ex. 16, p. 9 (emphasis omitted).) He adds that “inflammation and pathology that starts
in the subacromial space can easily travel to adjacent tissues such as the rotator cuff
and [acromioclavicular] joint, causing inflammation and pain in those areas as well.”
(Id.) Dr. Srikumaran suggested his opinion supports both a Table Injury of SIRVA, as
well as causation-in-fact of a shoulder injury. (Id. at 7, 9-10.)
In response, respondent filed an expert report by orthopedic surgeon Paul Cagle,
M.D.7 Dr. Cagle opines that petitioner’s pre-vaccination complaints of bilateral shoulder
pain, confirmed by imaging, and history of football-related injury, refute any assertion of
a Table SIRVA. (Ex. A, p. 6.) He further notes that petitioner’s chiropractic visit
occurring the day after vaccination confirms that there was no change in his condition at
that time, casting doubt on an abrupt (within 48 hours) post-vaccination onset of new
symptoms. (Id. at 6-7.) Relative to the third SIRVA QAI criterion, Dr. Cagle asserts that
the medical records do not document any reduction in range of motion. (Id. at 7.)
Whereas petitioner had documented reduced range of motion pre-vaccination (on
October 1, 2019), he was subsequently noted to have full range of motion on December
9, 2019. (Id.) In any event, Dr. Cagle opines petitioner’s condition is alternatively
explained by osteoarthritis, scapular symptoms, and SLAP tears, all unrelated to
vaccination. (Id. at 8.)
Dr. Cagle does not disagree that MRI results will often include age-related
findings. In this case, however, he opines that the “mild” bursitis demonstrated on
petitioner’s initial post-vaccination MRI is insufficient to demonstrate the type of robust
inflammatory response that can be related to SIRVA. (Ex. A, pp. 8-9.) Moreover, Dr.
Cagle disagrees that petitioner has demonstrated any shoulder injury caused-in-fact by
his vaccination because there is no evidence of a new onset of inflammation or any
other new structural shoulder injury. (Id. at 9.) Additionally, he charges that Dr.
Srikumaran’s opinion is too generic, asserting that “[s]imply saying the shoulder is
painful so it must be inflamed lacks scientific rigor and is fundamentally unsupported.”
(Id.)
7 Dr. Cagle received his medical degree from Loyola University Chicago Stritch School of Medicine in
2008, before going on to complete a residency in orthopedic surgery at the University of Minnesota
Academic Health Center and Medical School in 2013, as well as a shoulder and elbow fellowship at
Mount Sinai Hospital in New York, New York, and an additional shoulder fellowship at Private Hospital
Jean Mermoz/Centre Orthopaedic Santy in Lyon, France, in 2014. (Ex. B, p. 1.) He is a board certified
orthopedic surgeon. (Id. at. 2.) He currently works as an associate professor and associate program
director in the Department of Orthopedic Surgery at the Icahn School of Medicine at Mount Sinai. (Id. at
1; Ex. A, p. 1.) He is a member of the American Shoulder and Elbow Surgeons, as well as a member of
the American Academy of Orthopaedic Surgeons and the American Orthopaedic Association. (Ex. A, p.
1.) As a faculty member of an internationally recognized shoulder surgery fellowship, Dr. Cagle is
involved in teaching and educating medical students, graduate students, and orthopedic surgical
residents. (Id.) He also conducts clinical, biomedical, and basic science research. (Id. at 2.) He has
published over 90 publications and provided over 50 presentations pertaining to shoulder-related injuries.
(Ex. B, pp. 4-19.)
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In reply to Dr. Cagle, Dr. Srikumaran opines that evidence of bursitis on MRI will
be affected by a variety of factors, including anti-inflammatory treatments, such as those
received by petitioner prior to his MRI. (Ex. 36, p. 2.) He suggests that, in his own
clinical experience, the degree of buritis seen on MRI is not necessarily predictive of the
degree of bursitis later seen intraoperatively. (Id.) MRI is “only a piece of the puzzle”
and must be read in conjunction with petitioner’s physical exam findings, which
confirmed impingement. (Id.) Dr. Srikumaran further stresses that it is not structural
degeneration, but inflammation, that causes pain according to his theory of causation.
(Id.) Thus, the presence of pain and its temporally associated onset evidences new
inflammation and there is no need for any new structural issue. (Id.) In his second
report, Dr. Srikumaran also further discusses the experts’ differing interpretations of the
clinical history relative to the requirements for a Table SIRVA. (Id. at 1-3.)
IV. Discussion
In his motion for a ruling on the written record, petitioner argues both that his
bilateral shoulder injuries meet the Table requirements for SIRVA and, alternatively, that
he can demonstrate that he suffered a vaccine-caused significant aggravation of his
pre-existing shoulder pathology. (ECF No. 47.) In response, respondent disputes that
petitioner has demonstrated either type of injury. (ECF No. 48.) Moreover, he disputes
that petitioner has demonstrated that his condition persisted for at least six months.
(Id.) Because I find that petitioner is entitled to compensation for a significant
aggravation of his pre-existing shoulder pathology, I do not address petitioner’s Table
SIRVA allegations.
a. Loving prong one
Under the first Loving prong, the special master must make factual
determinations with respect to the petitioner’s pre-vaccination condition. W.C., 704 F.3d
at 1357. Petitioner argues that, while he had a medical history that included remote
prior shoulder dislocations, his shoulders were asymptomatic up to the point of the
vaccinations at issue. (ECF No. 47, pp. 10-11.) In that regard, petitioner stresses Dr.
Srikumaran’s opinion that petitioner’s positive Apley tests indicate only muscle
tightness, rather than pain. (Id. at 11.) By contrast, respondent argues that petitioner
did have active shoulder pain prior to vaccination (ECF No. 48, p. 13), but contends that
petitioner’s pre-vaccination records are inadequate to establish a specific or concrete
condition that could have been aggravated (Id. at 17-18). Based on my own review of
the record, neither party adequately grapples with the details of petitioner’s history.
Petitioner is not persuasive in arguing that he was asymptomatic prior to the
vaccinations at issue. Regardless of whether the Apley test is indicative of shoulder
pain, petitioner specifically sought care for, inter alia, bilateral shoulder pain, within the
weeks leading up to his vaccination. (Ex. 12.) When he first presented for evaluation
on October 1, 2019, he reported “constant” bilateral shoulder pain that he felt may be
related to his rotator cuff. (Id. at 6.) Moreover, at the time he was vaccinated, it was
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observed that petitioner was experiencing worsening obesity thought to be due to
inactivity related to joint and muscle pain. (Ex. 1, pp. 2, 4-5.) If petitioner’s remote
history of football injuries were the only issue, this would not necessarily prevent
petitioner from demonstrating a Table SIRVA. Accord O’Leary v. Sec’y of Health &
Human Servs., No. 18-584V, 2021 WL 3046617, at *8 (Fed. Cl. Spec. Mstr. June 24,
2021). However, given his explicit report of constant shoulder pain occurring weeks
prior to the time of vaccination, petitioner is not credible in arguing that he was
asymptomatic prior to vaccination.
Respondent is also not persuasive is seeking to underplay what can be fairly
understood regarding petitioner’s pre-vaccination condition. While it is true that
petitioner’s pre-vaccination records are thin with respect to specific findings of shoulder
pathology, both parties’ experts agree that, based on his later MRI results, petitioner
had pre-existing chronic shoulder pathology. (Ex. 16, p. 9; Ex. A, p. 8.) In that regard,
Dr. Cagle clearly argues both that petitioner’s condition is explained by osteoarthritis,
scapular symptoms, and SLAP tears, and that he suffered no new injury post-
vaccination. (Ex. A, p. 8.) Thus, Dr. Cagle necessarily argues that these findings
explain petitioner’s pre-existing condition and likely his symptoms. (Id.) Moreover, this
is at least partly consistent with the treating orthopedist’s assessment that petitioner’s
later post-vaccination condition was “primarily attributable to some combination of
[SLAP] and biceps tendon symptoms, and subacromial bursitis.” (Ex. 5, p. 2.)
Accordingly, the evidence preponderates in favor of a finding that petitioner was
suffering symptomatic shoulder pathology, likely inclusive of bilateral SLAP tears and
acromioclavicular osteoarthritis, affecting both of his shoulders prior to the vaccinations
at issue.
b. Loving prong two
Under the second Loving prong, the special master must make factual
determinations regarding the petitioner’s post-vaccination condition. W.C., 704 F.3d at
1357. Petitioner argues that, following vaccination, he suffered an acute onset of
worsened shoulder pain, which is explained by an inflammatory process that was
diagnosed as bursitis. (ECF No. 47, pp. 11-12; ECF No. 49, pp. 4-7.) Respondent
argues that petitioner has not identified a medically recognized injury that explains his
post-vaccination condition. (ECF No. 48, pp. 18-19.)
Pertinent to the analyses that follow, four factual determinations are necessary
and preponderantly supported with respect to petitioner’s post-vaccination condition:
• The severity of petitioner’s pain increased. When petitioner presented pre-
vaccination for his bilateral shoulder pain, he rated his pain as a 3-5 out of 10.
(Ex. 12, p. 6.) However, when treating with his primary care provider post-
vaccination, petitioner reported that his pain was “quite severe to the point
that he can no longer function doing his daily activities” and his physician
documented as part of the physical exam that he was “[o]bviously in
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significant pain.” (Ex. 2, pp. 14, 18.) When petitioner’s orthopedist later
documented a numerical rating, petitioner first reported his pain to be a 9 out
of 10 at worst and later indicated that his pain ranged from 6-8 out of 10. (Ex.
5, pp. 6, 10.)
• Petitioner had new onset of bursitis post-vaccination. Whereas petitioner’s
pre-vaccination exam found only positive Apley’s tests and was generally
characterized as limited by muscle tightness (Ex. 12, p. 9), his primary care
provider detected positive signs of impingement (Hawkins test) during his
post-vaccination exam, which she found concerning for bursitis (Ex. 2, p. 30).
Petitioner subsequently underwent a right shoulder MRI that detected bursitis,
albeit noted to be mild. (Ex. 14, p. 5.) Although Dr. Cagle questions the
significance of this finding given that it was noted to be mild (Ex. A, pp. 8-9),
Dr. Srikumaran reasonably suggests that the MRI results could have been
affected by petitioner’s prior treatment with steroids (Ex. 36, pp. 2-3).
Petitioner’s treating orthopedist subsequently diagnosed bilateral bursitis,
despite being aware the MRI report indicated only “mild” bursitis. (Ex. 5, pp.
11-12.)
• Subsequent to his development of buritis, petitioner also developed
symptoms of biceps tendinitis. Right-side biceps tendonitis was first
documented at petitioner’s March 12, 2020 orthopedic encounter. (Ex. 5, pp.
7-8.) And, indeed, petitioner’s Yergason’s test (a test for issues affecting the
biceps tendon) at his prior encounter of January 28, 2020, had been negative.
(Id. at 11.) It was not until his later encounter of May 4, 2020, that he was first
assessed and treated for a left-side biceps tendinitis. (Id. at 3-4.) Although
the tendinitis appears to have had a later onset than the bursitis, the treating
orthopedist did not distinguish petitioner’s tendinitis from the overall “flare” of
his pre-existing pathology. (E.g., id. at 2 (attributing bilateral shoulder pain to
“some combination of [SLAP] and biceps symptoms, and subacromial
bursitis”).) On petitioner’s behalf, Dr. Srikumaran incorporated tendinitis in his
assessment of petitioner’s vaccine-related injury. (Ex.16, pp. 10-11.)
However, Dr. Cagle did not discuss tendinitis in his own discussion of
petitioner’s condition, despite noting the treating orthopedist’s diagnosis in his
summary of the medical history. (Ex. A.)
• No other structural abnormality explains petitioner’s increased pain post-
vaccination. Both parties’ experts agree that petitioner had no new structural
abnormalities post-vaccination. (Ex. A, p. 9 (Dr. Abrams opining that “we
have no objective evidence of new onset inflammation or a new structural
shoulder injury as clearly demonstrated by the right shoulder MRI and the left
shoulder MRI”); Ex. 16, p. 9 (Dr. Srikumaran opining that, in petitioner’s own
case, inflammation acted upon chronic, asymptomatic shoulder pathology).)
c. Loving prong three
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Under the third Loving prong, the special master must assess whether a
comparison of the pre- and post-vaccination conditions constitutes a “significant
aggravation” of the condition at issue. W.C., 704 F.3d at 1357. The Vaccine Act
defines significant aggravation as “any change for the worse in a preexisting condition
which results in markedly greater disability, pain, or illness accompanied by substantial
deterioration of health.” § 300aa-33(4). Although petitioner need not prove the
expected outcome of his pre-vaccination condition or that her post-vaccination condition
is worse than the expected outcome, petitioner still must show that his post-vaccination
condition was affected by his vaccination. Locane v. Sec’y of Health & Human Servs.,
685 F.3d 1375, 1381 (Fed. Cir. 2012); Sharpe v. Sec’y of Health & Human Servs., 964
F.3d 1072, 1082 (Fed. Cir. 2020).
Petitioner argues that Dr. Greenawald’s encounter records demonstrate that,
following vaccination, petitioner experienced “a highly significant deterioration of [his]
condition,” noting the December 24, 2019 notation that “pain has been quite severe to
the point that he can no longer function doing his daily activities.” (ECF No. 47, p. 12
(emphasis omitted) (quoting Ex. 2, p. 14).) He argues that this marks a contrast to his
pre-vaccination records, which, despite documenting shoulder pain, did not document
that petitioner had any inability to function. (Id. (citing Ex. 12, pp. 10, 39).) He further
stresses Dr. Srikumaran’s observation that petitioner had new findings of impingement
post-vaccination. (Id. at 12-13.) Thus, petitioner argues that “petitioner experienced
new and/or exacerbated pain and disability following the November 19, 2019, flu and
hepatitis A vaccinations, thus, demonstrating a significant aggravation of any pre-
existing conditions.” (Id. at 13 (emphasis omitted).)
Comparing the findings made under Loving prongs one and two, I agree. Prior to
vaccination, petitioner was suffering constant shoulder pain likely related to bilateral
SLAP tears and acromioclavicular osteoarthritis. Following vaccination, petitioner
suffered a new onset of bursitis accompanied by symptoms of impingement and
significantly increased pain and then later biceps tendinitis. No condition other than the
bursitis is evidenced to explain the new symptoms. Thus, petitioner’s treating
orthopedist ultimately opined that petitioner was experiencing “bilateral shoulder pain,
primarily attributable to some combination of [SLAP] and biceps tendon symptoms, and
subacromial bursitis, in the setting of a flare after vaccination last year.” (Ex. 5, p. 2.)
That is, petitioner’s post-vaccination condition constituted a flare of his pre-existing
condition inclusive of symptoms caused in part by both his longstanding pathology and
his post-vaccinal subacromial bursitis.
Respondent argues, however, that “[p]etitioner has not properly pled his claim to
satisfy Loving prong three.” (ECF No. 48, p. 19.) He contends that “[t]he
amorphousness of SIRVA as a significant aggravation injury subsumes a prior
condition: by using ‘SIRVA’ as his current condition, petitioner simply assumes several
shoulder pathologies can be aggravated by vaccination, without specifying or providing
evidence for any particular one.” (Id.) Respondent also argues that “relying on Dr.
Srikumaran’s analysis to evaluate the Loving prongs is flawed because Dr. Srikumaran
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was fundamentally mistaken that petitioner’s prior condition was ‘asymptomatic.’” (Id. at
18.)
Respondent’s argument misconstrues petitioner’s filings. While respondent is
obviously correct to suggest that SIRVA can subsume pre-existing asymptomatic
pathologies, petitioner has not merely relied on the broader concept of SIRVA to explain
his current, aggravated condition. Petitioner’s amended petition was explicit in pleading
significant aggravation “[i]n the alternative” to SIRVA (ECF No. 19, p. 1), and he is clear
within his motion for a ruling on the written record in arguing that his vaccinations
caused bursitis, which is a specific condition. (ECF No. 47, pp. 10-17.) This is also
consistent with how I have addressed significant aggravation in prior cases. E.g., Kelly
v. Sec’y of Health & Human Servs., No. 17-1918V, 2022 WL 1144997 (Fed. Cl. Spec.
Mstr. Mar. 24, 2022). How bursitis can aggravate pre-existing shoulder pathology is
addressed further under Loving prongs four and five.
I have also considered respondent’s argument regarding Dr. Srikumaran’s
credibility. Accord Pulsipher v. Sec’y of Health & Human Servs., No. 21-2133V, 2025
WL 1364203, at *13 (Fed. Cl. Spec. Mstr. Apr. 24, 2025) (rejecting Dr. Srikumaran’s
opinion in part because “Dr. Srikumaran’s predicate assumption that petitioner initially
suffered bursitis, as called for by his theory of causation, is unsupported speculation”),
mot. for rev. denied, No. 21-2133, 2025 WL 3526353 (Fed. Cl. Sep. 3, 2025). However,
while petitioner did himself argue first and foremost that he was asymptomatic prior to
vaccination, I do not agree with respondent’s characterization of Dr. Srikumaran’s
opinion. In asserting a Table SIRVA, Dr. Srikumaran clearly opined that “[a]lthough the
petitioner did have a history of shoulder pain, it does not explain the signs, symptoms,
examination findings, and diagnostic studies that occurred after the vaccination.” (Ex.
36, p. 1 (emphasis omitted).) This is not the same thing as asserting the petitioner was
previously asymptomatic. Moreover, in asserting causation-in-fact, Dr. Srikumaran
asserted that petitioner’s “shoulder symptoms were mild prior to the vaccinations, and
increased to severe following the vaccinations . . . . the time course of events supports
that he had a significant aggravation of a condition that existed prior to vaccination.”
(Ex. 16, p. 11.)
In light of the above, there is preponderant evidence that petitioner’s post-
vaccination condition constitutes a significant aggravation of his pre-existing shoulder
condition.
d. Loving prong four
Petitioner’s burden under the first Althen prong/fourth Loving prong is to provide,
by preponderant evidence, “a medical theory causally connecting the vaccination and
the injury.” Althen, 418 F.3d at 1278; W.C., 704 F.3d at 1357. 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). Moreover, scientific evidence
offered to establish Althen prong one is viewed “not through the lens of the laboratorian,
but instead from the vantage point of the Vaccine Act’s preponderant evidence
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standard.” Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1380 (Fed. Cir.
2009). However, to satisfy this prong, petitioner’s theory must be based on a “sound
and reliable medical or scientific explanation.” Knudsen, 35 F.3d at 548; Boatmon v.
Sec’y of Health & Human Servs., 941 F.3d 1351, 1359 (Fed. Cir. 2019). Petitioner’s
burden under Loving prong four varies from the burden under Althen prong one in that a
significant aggravation claim requires petitioner only to show that the vaccine at issue
can worsen the condition at issue, rather than be its cause. Sharpe v. Sec’y of Health &
Human Servs., 964 F.3d 1072, 1083 (Fed. Cir. 2020) (explaining that, “[u]nder Loving
prong 4, a petitioner need only provide ‘a medical theory causally connecting
[petitioner’s] significantly worsened condition to the vaccination’” (second alteration in
original) (quoting Loving, 86 Fed. Cl. at 144)).
Petitioner argues that Dr. Srikumaran has demonstrated that inflammation
caused by vaccination in or near the bursa can result in subacromial bursitis that
initiates pain from chronic degenerative changes and that inflammation of the
subacromial space can further affect adjacent structures, such as the rotator cuff and
acromioclavicular joint. (ECF No. 47, p. 13 (discussing Ex. 16, pp. 9-16).) Respondent
argues, however, that
Dr. Srikumaran’s theory is neither reputable nor persuasive in this case
because it fails to account for a vaccinee with a prior symptomatic condition.
Indeed, merely that vaccines induce some inflammation as a general
immunologic proposition does not establish that vaccination was the
substantial and but-for cause of petitioner’s post-vaccination condition.
(ECF No. 48, p. 21.)
I addressed a substantially similar argument in the prior Kelly case. 2022 WL
1144997, at *22-23. In that case, I agreed with respondent that a significant limitation of
much of the SIRVA literature, such as the seminal Atanasoff study cited in the
Secretary’s SIRVA rulemaking, is that it isolated SIRVA as a phenomenon based on the
absence any confounding symptoms. Specifically, I explained that “[t]he Atanasoff
authors stressed that there is no diagnostic test available to assess whether shoulder
dysfunction is vaccine-caused, leaving only this type of clinical qualification to aid in
identifying post-vaccination shoulder injuries as a distinct entity.” Id. at *22.
Importantly, however, in the Kelly case and in this case, Dr. Srikumaran has also cited
an epidemiologic study by Hesse et al., which demonstrated an elevated risk of
subdeltoid bursitis following vaccination. 2022 WL 114997, at *22; Elisabeth M. Hesse
et al., Risk of Subdeltoid Bursitis After Influenza Vaccination: A Population-Based
Cohort Study, 173 ANNALS INTERNAL MED. 253 (2020) (Ex. 29). Thus, even respondent’s
own expert in this case agrees that “[i]t is clear from the SIRVA literature that a SIRVA
can cause inflammation of the shoulder.” (Ex. A, p. 9.) Therefore, the evidence
preponderates in favor of a finding that vaccines can cause subacromial bursitis.
With a relationship between vaccination and bursitis established, the only
remaining question is whether it is sound and reliable for Dr. Srikumaran to theorize that
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subacromial bursitis can activate pain in adjacent structures of the shoulder. On that
point, Atanasoff et al. explained:
In general, chronic shoulder pain with or without reduced shoulder joint
function can be caused by a number of common conditions including
impingement syndrome, rotator cuff tear, biceps tendonitis, osteoarthritis
and adhesive capsulitis. In many cases, these conditions may cause no
symptoms until provoked by trauma or other events. Reilly et al. reviewed
a series of shoulder ultrasound and MRI studies obtained in asymptomatic
persons past middle age and found partial or complete rotator cuff tears in
39% of those individuals. Therefore, some of the MRI findings in our case
series, such as rotator cuff tears, may have been present prior to
vaccination and became symptomatic as a result of vaccination-associated
synovial inflammation.
(S. Atanasoff et al., Shoulder Injury Related to Vaccine Administration (SIRVA), 28
VACCINE 8049 (2010) (Ex. 18, p. 3) (citations omitted).)
In effect, Dr. Srikumaran reasonably opines that if subacromial bursitis can be
shown to generate pain in adjacent shoulder structures in previously asymptomatic
patients, then its pain generating potential is established in all events. Neither logic, nor
any evidence on this record, would support the notion that the same mechanism would
not also apply if the pre-existing pathology at issue were already painful. Instead,
respondent’s argument to the contrary – that prior symptoms preclude a finding that the
vaccination was a but-for cause and substantial contributing factor – speaks to actual
causation under Loving prong five, rather than general causation under Loving prong
four.
Regarding the specific pre-existing pathology at issue in this case, Dr.
Srikumaran cited a study examining the clinical characteristics of conceded SIRVA
claims. (Elisabeth M. Hesse et al., Shoulder Injury Related to Vaccine Administration
(SIRVA): Petitioner Claims to the National Vaccine Injury Compensation Program,
2010-2016, 38 VACCINE 1076 (2020) (Ex. 28).) With regard to MRI findings, the study
documented that 16.2% of SIRVAs had evidence of labral tears, 16.2% had
acromioclavicular arthritis, and 6.5% had findings referable to the biceps tendon. (Id. at
5 tbl. 5.) Additionally, among surgical cases, 29.7% underwent rotator cuff repair in
treatment of their SIRVA and 5.2% underwent a labral or SLAP repair. (Id. at 6 tbl. 6.)
While this alone does not suffice to demonstrate that these findings were pain
generators in these cases, Pulsipher, 2025 WL 1364203, at *12, Atanasoff et al.
specifically hypothesize that biceps tendinitis and osteoarthritis may be among the
conditions activated by bursitis. And, while many prior decisions have noted that SLAP
tears are not caused by vaccination, it has also been observed that they can interact
with SIRVA pathology to cause pain and suffering. Garcia v. Sec’y of Health & Human
Servs., No. 19-1529V, 2025 WL 1159016, at *8 (Fed. Cl. Spec. Mstr. Mar. 21, 2025)
(explaining with regard to a SLAP tear that a petitioner’s SIRVA “may have
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compounded her pain and suffering connected with those comorbid conditions, [but] it
did not cause them”).
e. Loving prong five
The second Althen prong/fifth Loving prong requires proof of a logical sequence
of cause and effect showing that the vaccine was the reason for the injury, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at
1278; W.C., 704 F.3d at 1357; Andreu, 569 F.3d at 1375-77; Capizzano v. Sec’y of
Health & Human Servs., 440 F.3d 1317, 1326 (Fed. Cir. 2006); Grant v. Sec’y of Health
& Human Servs., 956 F.2d 1144, 1148 (Fed. Cir. 1992). However, medical records
and/or statements of a treating physician do not per se bind the special master to adopt
the conclusions of such an individual, even if they must be considered and carefully
evaluated. 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)
(stating that “there 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).
In this case, the evidence preponderates in favor of a finding that petitioner’s
treating physicians felt that his vaccinations likely exacerbated his underlying shoulder
pathology. Initially, petitioner’s primary care provider felt that “[i]t is possible that both
vaccines were given too superiorly and caused a bursitis.” (Ex. 9, p. 38.) Later, his
orthopedist assessed bilateral bursitis (Ex. 5, p. 11) and explained that petitioner’s
bilateral shoulder pain was “in [the] setting of injection, on evaluation, differential
includes, or perhaps is a combination of, subacromial bursitis, possible mild Parsonage-
Turner syndrome, SI[R]VA” (Id. at 12). The orthopedist remarked that, based on history
and examination, concern for any significant rotator cuff tear was low. (Id.) After
petitioner later began reporting symptoms of biceps tendinitis, the orthopedist ultimately
characterized petitioner’s condition as representing “some combination of [SLAP] and
biceps tendon symptoms, and subacromial bursitis, in the setting of a flare after
vaccinations.” (Id. at 2.) Petitioner also argues that these opinions are further
supported by Dr. Srikumaran’s opinion and theory. (ECF No. 47, p. 15.)
Respondent argues, however, that the facts of petitioner’s own case do not align
with Dr. Srikumaran’s explanation for several reasons. (ECF No. 48, pp. 22-24.) The
worsening of petitioner’s symptoms did not occur over a time course consistent with Dr.
Srikumaran’s theory. (Id. at 22.) That is, onset of his pain was not immediate after
vaccination, and he did not experience reduced range of motion until about five weeks
post-vaccination. (Id. at 22-23.) Additionally, petitioner’s right-side MRI showed only
mild bursitis, which respondent’s expert opined is inconsistent with SIRVA. (Id. at 23.)
His later left-side MRI showed no evidence of bursitis. (Id. at n. 9.) Furthermore, the
radiologist’s interpretation included a note of undersurface osteophytes relative to
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petitioner’s observed acromioclavicular osteoarthritis, which “could” explain petitioner’s
impingement. (Id. at 23.) And, finally, “petitioner’s applied theory and sequence of
events is undermined by his well-documented shoulder pathology that was symptomatic
prior to his vaccinations and would be expected to worsen with aging and activity.” (Id.)
Respondent’s argument with respect to timing is addressed under Loving prong
six. Because it is not persuasive relative to Loving prong six, it is also not persuasive
with respect to Loving prong five. Respondent’s argument with respect to the expected
course of petitioner’s pre-existing pathology is also largely addressed by the analyses of
the other Loving prongs. Specifically, as explained under Loving prong three, petitioner
is not obligated to prove the expected outcome of his pre-vaccination condition or that
his post-vaccination condition is worse than the expected outcome. Sharpe, 964 F.3d at
1082. Instead, he must only demonstrate that his condition was affected by his
vaccination. Locane, 685 F.3d at 1381. As explained under Loving prong two, the
evidence preponderates in favor of a finding that petitioner developed bursitis post-
vaccination, that he experienced a significant change in his symptoms, and that this
change in symptoms was due to his diagnosed bursitis. And, as discussed above
relative to Loving prong five, both Dr. Srikumaran and petitioner’s treating physicians
opined that petitioner’s bursitis was likely vaccine-related and a significant factor in his
post-vaccination condition. Only Dr. Cagle’s competing assessment of the bursitis is to
the contrary; however, Dr. Cagle is not persuasive on this point.
In his report, Dr. Cagle cites his own review of the SIRVA literature for the
proposition that the observation of “mild bursitis” on petitioner’s right shoulder MRI
“speak[s] strongly against a SIRVA. The SIRVA literature clearly has shown that the
robust inflammatory response that occurs with an actual SIRVA caus[es] a significant
fluid formation (bursitis).” (Ex. A, pp. 8-9 (citing Paul J. Cagle Jr., Shoulder Injury After
Vaccination: A Systematic Review, 56 REVISTA BRASILIERA DE ORTOPEDIA 299 (2021)
(Ex. A, Tab 1)).) However, after reviewing the paper cited by Dr. Cagle, I do not see
where it ever characterizes the degree of bursitis that would be indicative of a SIRVA or
SIRVA-like inflammatory process. (Cagle, supra, at Ex. A, Tab 1, p. 3.) While Dr.
Cagle does discuss some prior papers that include specific reference to effusions, he
also discusses papers that included only “minor effusions” and noted that Atanasoff et
al. observed fluid collection in only 69% of SIRVA subjects. (Id.) Ultimately, Dr. Cagle
indicated that “early MRI findings after a SIRVA event correlated with inflammatory
changes such as increased fluid, buritis and tendinitis.” (Id.) Respondent also notes
the fact that petitioner’s later left shoulder MRI showed no evidence of bursitis, seeming
to suggest this should cause doubt on the finding of bursitis on the earlier right shoulder
MRI. However, Dr. Cagle’s paper suggests that “MRIs taken months later may not be
an accurate method of assessment.” (Id.) Significantly, Dr. Cagle contests the idea that
petitioner had any significant bursitis as evidence of a “new onset of inflammation” that
would support Dr. Srikumaran’s assessment. (Ex. A, p. 9.) He does not specifically
identify any other cause of petitioner’s diagnosed bursitis.
Respondent’s citation to the radiologist’s impression regarding the presence of
osteophytes is also not persuasive. The radiologist’s impression that the osteophytes
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“could contribute” to impingement is tentatively stated and lacks any clinical correlation.
(Ex. 14, p. 5.) Instead, when petitioner first presented for orthopedic care, the
orthopedist specifically diagnosed petitioner’s condition as bursitis after reviewing the
radiologist’s MRI report. (Ex. 5, pp. 11-12.) And, although Dr. Cagle noted the fact of
the radiologist’s observation of osteophytes (Ex. A, p. 4), he did not endorse
osteophytes as a cause of petitioner’s impingement or as a cause of his condition (Id. at
6-9).
Accordingly, there is preponderant evidence of a logical sequence of cause and
effect whereby petitioner’s bilateral vaccinations did cause a significant aggravation of
petitioner’s pre-existing shoulder condition.
f. Loving prong six
The third Althen prong/sixth Loving prong requires establishing a “proximate
temporal relationship” between the vaccination and the injury alleged. Althen, 418 F.3d
at 1281; W.C., 704 F.3d at 1357. That term has been equated to the phrase “medically-
acceptable temporal relationship.” Althen, 418 F.3d at 1281. A petitioner must offer
“preponderant proof that the onset of symptoms occurred within a timeframe 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).
Petitioner asserts in his briefing that Loving prong six should be assessed in
accordance with the 48-hour onset period otherwise recognized in the context of a
Table SIRVA. (ECF No. 47, p. 16 (arguing onset occurred within 48 hours); ECF No.
49, p. 9 (requesting judicial notice of the Table SIRVA onset period). Respondent does
not take a position relative to Loving prong six as to what would constitute a medically-
acceptable temporal relationship as a general matter (ECF No. 48, pp. 24-25); however,
as noted above, he argued with respect to Loving prong five that Dr. Srikumaran’s
theory calls for an “immediate injection-related pain” affecting the bursa (Id. at 22).
As discussed above, Dr. Srikumaran’s theory of causation is that petitioner’s
vaccinations caused an inflammatory response affecting the bursa and resulting in
bursitis. This bursitis, in addition to being painful itself, aggravated petitioner’s pain and
shoulder dysfunction related to his pre-existing shoulder pathology. And, as explained
under Loving prong four, one study cited by Dr. Srikumaran in support of his theory,
Hesse et al., found an elevated risk of bursitis occurring after vaccination. (Hesse et al.,
supra, at Ex. 29.) Pertinent to Loving prong six, the elevated period of risk was up to 3
days post-vaccination. (Id. at 4.)
In this case, when petitioner sought treatment for his shoulder pain, he
repeatedly associated a new onset of acute pain with his vaccinations. (Ex. 2, pp. 14,
31; Ex. 5, p. 10.) However, respondent stresses that petitioner had a chiropractic
appointment for, inter alia, his bilateral shoulder pain the day after the vaccinations at
issue. (ECF No. 48, p. 22 (citing Ex. 12, p. 41).) As of that encounter, it was noted that
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petitioner was doing “okay” and that he had no new symptoms. (Id.) This is the only
reason respondent provides for doubting the initial onset of petitioner’s shoulder pain.
Importantly, however, this raises an issue only under respondent’s assumption that
shoulder pain must have occurred “immediately,” which I do not find to be the relevant
onset period. In that regard, petitioner’s affidavit account indicated that the onset of his
shoulder pain occurred “[w]ithin 2 days” of his vaccination, which remains consistent
with Dr. Srikumaran’s theory and the fact of the November 20, 2019 chiropractic
assessment. (Ex. 10, p. 1.)
Accordingly, there is preponderant evidence that petitioner suffered onset of
bilateral shoulder pain, consistent with a post-vaccination bursitis, within a timeframe
from which a causal inference can be drawn.
g. Factor unrelated to vaccination
Once petitioner has met his own prima facie burden of proof, respondent may still
demonstrate by a preponderance of evidence that the injury was nonetheless caused by
a factor unrelated to the vaccination. § 300aa-13(a)(1)(B). In this case, respondent
argued relative to both petitioner’s Table SIRVA claim, as well as his significant
aggravation claim, that petitioner’s pre-existing shoulder pathology prevents him from
meeting his own burden of proof. (ECF No. 47, pp. 17, 23.) These arguments are
addressed by the preceding analyses. Respondent has not otherwise argued that he
can affirmatively demonstrate under a shifted burden of proof that petitioner’s pre-
existing shoulder pathology explains his alleged injury. Nor has respondent presented
any other argument with respect to any other factor unrelated to vaccination.
h. Severity requirement
In order to state a claim for a vaccine-related injury under the Vaccine Act, a
vaccinee must have either:
(i) suffered the residual effects or complications of such illness, disability,
injury, or condition for more than 6 months after the administration of the
vaccine, or (ii) died from the administration of the vaccine, or (iii) suffered
such illness, disability, injury, or condition from the vaccine which resulted
in inpatient hospitalization and surgical intervention.
§ 300aa-11(c)(1)(D). In this case, only the first of these conditions is potentially met.
Neither “residual effects” nor “complication” is defined within the Vaccine Act
itself. See § 300aa-33. However, in Wright v. Secretary of Health & Human Services,
the Federal Circuit described these terms as follows: “‘Residual’ suggests something
remaining or left behind from a vaccine injury. An effect that is ‘residual’ or ‘left behind’
is one that never goes away or that recurs after the original illness.” 22 F.4th 999, 1005
(Fed. Cir. 2022) (internal citation omitted). A “complication,” however, is a “morbid
process or event occurring during a disease which is not an essential part of the
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disease, although it may result from it.” Id. at 1006 (quoting Abbott v. Sec’y of Health &
Human Servs., 27 Fed. Cl. 792, 794 (1993)).
Read together, “residual effects” and “complications” appear to both refer
to conditions within the patient, with “residual effects” focused on lingering
signs, symptoms, or sequelae characteristic of the course of the original
vaccine injury, and “complications” encompassing conditions that may not
be “essential part[s] of the disease” or may be outside the ordinary
progression of the vaccine injury.
Id. (alteration in original).
Respondent argues that petitioner sought regular and persistent treatment of his
shoulder condition for only five and a half months post-vaccination. (ECF No. 48, p.
12.) Thereafter, the medical records reflect a 13-month gap in treatment for which
respondent does not agree that the Covid-19 pandemic offers a reasonable explanation.
And, although petitioner later returned to care, respondent argues that he
has not established that the recurrence of his bilateral shoulder pain on
June 14, 2021 was caused by his alleged SIRVA; rather, petitioner’s
recurrence of bilateral shoulder pain is consistent with his thirty-year history
of waxing and waning bilateral shoulder symptomology and extensive
shoulder pathology that includes numerous findings of degeneration as well
as bilateral SLAP tears.
(Id.)
In reply, petitioner argues that, in light of pandemic-related restrictions and the
availability of a home exercise program from his orthopedist, it was reasonable for
petitioner to forgo further in-person follow up. (ECF No. 49, pp. 1-2.) Moreover, at the
time of his May 4, 2020 encounter, he was just two-weeks shy of the six month mark
and, at that time, he was administered a steroid injection into his shoulder and his
orthopedist advised that he may still be a candidate for shoulder surgery. (Id. at 2
(citing Ex. 5, p. 4).) Thus, petitioner argues that it is not reasonable to assume that
petitioner’s condition would have completely resolved within two weeks. (Id.)
In Kirby v. Secretary of Health & Human Services, the Federal Circuit confirmed
that it is not an error for a special master to find the severity requirement met where that
finding is based on a collection of “plausible evidence.” 997 F.3d 1378, 1381 (Fed. Cir.
2021). In that case, petitioner’s medical records reflected active treatment of her
condition for only a few months before she was released as having reached maximum
medical improvement, though not entirely symptom free. Id. at 1380. Thereafter, the
medical records were silent as to her alleged residual effects for the remaining duration
of the six-month post-vaccination period. Id. However, petitioner testified that she
continued a home exercise plan for more than a year. Id. at 1381. Her testimony was
corroborated by documentation in the form of her retained home exercise sheet, a more
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remote return visit where the relevant symptoms were again reported, and an expert
opinion confirming her reported symptoms were consistent with her injury. Id. The
Federal Circuit concluded that where the medical records are silent, rather than
contradictory, it was not error for the special master to credit the petitioner’s
corroborated testimony as evidence satisfying the six-month severity requirement. Id. at
1383-84.
Here, similar to the Kirby petitioner, this petitioner averred that he remained
symptomatic after his formal treatment ended in May of 2020 and that he continued to
follow instructions for at home rehabilitation exercises. (Ex. 10, p. 2.) In that regard, the
medical records confirm that petitioner was taught a home exercise program as part of
his physical therapy. (Ex. 3, p. 8.) And, whereas the Kirby petitioner’s absence from
continued treatment was explained by having reached maximum medical improvement,
this petitioner’s absence from treatment is reasonably explained by the Covid-19
pandemic. Accord Tackett v. Sec’y of Health & Human Servs., No. 20-1705V, 2023 WL
6995391, at *9 (Fed. Cl. Spec. Mstr. Sep. 25, 2023) (finding the severity requirement
met where treatment stopped after five months and placing “significant weight on the
disruptions caused by the Covid-19 pandemic as the reason petitioner stopped
attending physical therapy when he did”). Furthermore, the nature of petitioner’s
condition at the time of his May 4, 2020 encounter is significant. That is, the medical
records confirm that, as of five-and-a-half months post-vaccination, petitioner was still
symptomatic by physical exam, still assessed as having both bursitis and tendinitis at
that time, received treatment as of that date, and was advised that surgery remained a
potential next step. (Ex. 5, pp. 3-4.) Nothing in the medical record suggests that
petitioner’s condition was resolved at that time or expected to resolve promptly.
Accordingly, considering all of this, I find that petitioner has satisfied the severity
requirement by preponderant evidence, albeit just barely, regardless of whether his later
presentation in June of 2021 and later represents a continuation of the injury.
On the current record, I am not persuaded that petitioner has demonstrated that
his current condition, or the condition for which he sought treatment after June of 2021,
are sequela of his vaccine-related injury.8 Whereas petitioner’s statements reflect that
he himself views his current condition as a continuation of his injury, there is no medical
opinion available to support that belief. Contrary to petitioner’s statement that his
shoulder pain never resolved (Ex. 38), petitioner’s June 14, 2021 medical record
indicates that, at some time during his 13-month gap in treatment, his pain and become
“intermittent” (Ex. 7, p. 9). Moreover, whereas petitioner’s significant aggravation of his
shoulder pathology was in part evidenced by the fact that he went from merely
experiencing pain to experiencing debilitation, his later medical records reflect that he
check-marked in July of 2021 that he is able to work or play sports (Id. at 6) and his
subjective pain rating ranged from 3-6 out of 10, which is not dissimilar to his pre-
vaccination rating of 3-5 out of 10 (Compare id., with Ex. 12, p. 6). Further still,
petitioner’s June 14, 2021, and July 12, 2021, encounter records indicate that his
current condition was sequela to working out recently. (Ex. 7, p. 9 (“Patient reports he
8 Because entitlement does not turn on this issue for the reasons discussed above, this may be further
addressed in the damages phase of litigation.
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has been working his muscles recently.”); id. at 1 (“Patient had previously stated
soreness in the biceps after working out . . . .”).) And, whereas petitioner’s orthopedist
had previously felt the concern for a significant rotator cuff tear was low (Ex. 5, p. 12),
he felt petitioner’s 2021 MRI was concerning for a near full-thickness rotator cuff tear of
uncertain magnitude (Ex. 7, pp. 2-3). In contrast to his 2019 and 2020 medical records,
none of the updated orthopedic records discuss petitioner’s 2021 condition as a
continuation of the “flare” he had previously experienced. (Ex. 7.) Although Dr.
Srikumaran’s report suggests that petitioner’s “current condition is well documented in
the medical records” (Ex. 16, p. 11), he did not meaningfully discuss these issues or
explicitly opine that the findings from 2021 represent an ongoing aggravation of
petitioner’s condition.
V. Conclusion
After weighing the evidence, and considering the record as a whole, I find that
petitioner has preponderantly demonstrated that he is entitled to compensation for a
significant aggravation of bilateral shoulder pathology caused-in-fact by his November
19, 2019 vaccinations. A separate damages order will be issued
IT IS SO ORDERED.
s/Daniel T. Horner
Daniel T. Horner
Special Master
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