VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_21-vv-00549
Package ID: USCOURTS-cofc-1_21-vv-00549
Petitioner: Jared Trinnaman
Filed: 2021-01-11
Decided: 2024-05-31
Vaccine: influenza
Vaccination date: 2019-09-23
Condition: shoulder injury related to vaccine administration (SIRVA)
Outcome: denied
Award amount USD: 

AI-assisted case summary:
Jared Trinnaman, a 36-year-old adult, received an influenza vaccine on September 23, 2019. Approximately two weeks later, he began experiencing right shoulder pain and reported an inability to move his arm. He was diagnosed with adhesive capsulitis, and his condition was noted as slowly improving. The case proceeded as a Table claim for Shoulder Injury Related to Vaccine Administration (SIRVA). However, the court ultimately denied compensation. The primary reason for denial was that Mr. Trinnaman failed to meet the statutory severity requirement, which mandates that residual effects of the injury must persist for more than six months post-vaccination. The court found that Mr. Trinnaman's medical treatment records showed significant gaps, particularly a seven-month period between October 2019 and March 2020, and another three-month gap later. Despite Mr. Trinnaman's explanation that his extensive work travel prevented him from seeking consistent medical care, the court found that his travel records indicated he sought treatment when necessary for other issues, suggesting he would have done so for his shoulder if symptoms had persisted. Furthermore, later medical appointments in May, September, and October 2020, while addressing shoulder pain, were often telemedicine visits with no physical examination, and the treating physicians speculated about alternative causes or noted improvement. The court concluded there was insufficient evidence of continuous symptoms through the required six-month period. Consequently, the petition was dismissed.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_21-vv-00549-0
Date issued/filed: 2024-02-01
Pages: 8
Docket text: PUBLIC DECISION (Originally filed: 12/11/2023) regarding 32 DECISION of Special Master ( Signed by Chief Special Master Brian H. Corcoran. )(mpj) Service on parties made.
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Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 1 of 8
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 21-0549V
JARED TRINNAMAN, Chief Special Master Corcoran
Petitioner, Filed: December 11, 2023
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Influenza (Flu) Vaccine; Shoulder
HUMAN SERVICES, Injury Related to Vaccine
Administration (SIRVA); Six Month
Respondent. Severity Requirement
Laura Levenberg, Muller Brazil PA, Dresher, PA, for Petitioner.
Julia Marter Collison, U.S. Department of Justice, Washington, DC, for respondent.
DECISION DISMISSING CASE1
On January 11, 2021, Jared Trinnaman 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 he suffered a shoulder injury related to vaccine
administration (“SIRVA”) following an influenza (“flu”) vaccine he received on September
23, 2019. Petition at 1. This case was assigned to the Special Processing Unit of the
Office of Special Masters.
Respondent argues that the claim cannot meet the Vaccine Act’s “severity
requirement,” and for the reasons stated below, I deem the claim appropriately dismissed
on that basis.
1 Because this Decision contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government
Services). This means the Decision will be available to anyone with access to the internet. In
accordance with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other
information, the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I
agree that the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2018).

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 2 of 8
I. Procedural History
On February 3, 2023, Respondent filed his Rule 4(c) Report arguing that
“Petitioner is not entitled to compensation because he has not established that he
suffered from an alleged vaccine-related shoulder injury for more than six months post-
vaccination.” Rule 4(c) at 5. Petitioner filed a Motion for Ruling on the Record (“Mot.”) on
March 6, 2023. ECF No. 27. Respondent filed a response (“Opp.”) on April 26, 2023, and
Petitioner filed a reply (“Reply”) on May 11, 2023. ECF No. 28, 31. The matter is ripe for
resolution.
II. Factual Background
Petitioner was 36 years old when he received the flu vaccine in his right deltoid at
his primary care provider’s (“PCP”) office on September 23, 2019. Ex. 3 at 1.
Two weeks later, on October 8, 2019, Petitioner had a telephone appointment with
his PCP, at which time he reported right shoulder pain after the vaccination. Ex. 4 at 90.
Petitioner stated that he had tried ice and rest, but that he did “not want to try medication
for pain/inflammation,” and requested an in-person exam. Id.
The following day, Petitioner saw his PCP as requested. Ex. 4 at 101. Petitioner
reported pain since the vaccination, and an “inability to move his arm.” Id. On exam, he
had full passive range of motion without pain, but reported pain with active range of
motion. Id. at 102. He was offered physical therapy. Id. During a telephone follow-up later
that evening, Petitioner reported receiving the vaccination “high in the right shoulder,” and
that the pain was “dull aching to sharp at 8/10 if lifting.” Id. at 107. Petitioner “insist[ed] on
xray and seeing orthopedics,” but declined an orthopedic appointment the follow day due
to travel. Id. at 109. Petitioner requested an appointment the following Tuesday (October
15, 2019). Id. Petitioner had an x-ray the following day, October 10, 2019, which was
normal. Id. at 131.
On October 15, 2019, Petitioner was examined by an orthopedist. Ex. 4 at 139. He
reported shoulder pain and stiffness that was “slowly getting better.” Id. He was diagnosed
with adhesive capsulitis, and advised to do online physical therapy3 and to use ibuprofen
rather than a narcotic medication. Id. at 142. The orthopedist noted that “he is already
getting better and has made tremendous gains in a short period of time,” and explained
that “this should resolve on its own with more time.” Id.
3 There is no evidence in the record that Petitioner ever attended any physical therapy sessions, however,
or performed the recommended therapy by himself.
2

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 3 of 8
Petitioner returned to his PCP on October 30, 2019, with skin and toenail
complaints. Ex. 4 at 166. Although there was no examination of his shoulder, Petitioner
requested and received a refill of acetaminophen, with codeine for his right shoulder pain.
Id. at 168.
Petitioner next sought medical treatment five months later, on March 10, 2020,
when he visited his PCP for a right finger infection. Ex. 4 at 180. He made no mention of
shoulder issues at this time. Then, on May 26, 2020, Petitioner had a telephone
appointment with his orthopedist, during which he stated that he continued to have pain
with lifting and overhead motion. Ex. 4 at 197. No examination was performed. Id. The
doctor speculated that Petitioner’s symptoms could be rotator cuff tendinitis or lingering
pain from adhesive capsulitis, and recommended an in-person evaluation. Id. He did not
believe an MRI was necessary. Id.
On September 5, 2020, Petitioner had a video appointment with his PCP for a rash,
foot pain, and skin and nail issues. Ex. 4 at 213. His medical history referenced “frozen
shoulder resulting from a flu shot.” Id. No shoulder examination was performed. Petitioner
wanted to avoid anti-inflammatories, including cortisone injections, for his right shoulder
pain. Id. at 214. Blood work and x-rays were ordered to address Petitioner’s joint pain. Id.
The bloodwork showed Petitioner’s rheumatoid factor to be slightly elevated. Id. at 241.
On October 30, 2020, Petitioner had a video appointment with his PCP with
complaints of continued right shoulder pain. Ex. 4 at 250. He stated he was “doing some
exercises . . . but continues with some pain,” particularly with overhead movement. Id.
The records notes that Petitioner “does appear to have full range of motion of shoulders.”
Id. at 251. The doctor recommended that he continue exercises to maintain range of
motion, and possibly, a cortisone injection if there was no improvement. Id.
On December 16, 2020, Petitioner had a video appointment with his PCP for
issues unrelated to his shoulder pain. Ex. 4 at 271. The record does not mention right
shoulder symptoms. There are no further records evidencing additional treatment for
Petitioner’s shoulder pain.
III. Authority
The Vaccine Act requires that a petitioner demonstrate that “residual effects or
complications” of a vaccine-related injury continued for more than six months. Vaccine
Act §11(c)(1)(D)(i). A petitioner cannot establish the length or ongoing nature of an injury
merely through self-assertion unsubstantiated by medical records or medical opinion.
§13(a)(1)(A). “[T]he fact that a petitioner has been discharged from medical care does not
necessarily indicate that there are no remaining or residual effects from her alleged
3

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 4 of 8
injury.” Morine v. Sec’y of Health & Human Servs., No. 17-1013V, 2019 WL 978825, at
*4 (Fed. Cl. Spec. Mstr. Jan. 23, 2019); see also Herren v. Sec’y of Health & Human
Servs., No. 13-1000V, 2014 WL 3889070, at *3 (Fed. Cl. Spec. Mstr. July 18, 2014).
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 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 & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir.
1993).
Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this rule
does not always apply. In Lowrie, the special master wrote that “written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Lowrie, at *19. 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 & Human Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).
The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Human Servs., 42 Fed.
Cl. 381, 391 (1998). The Court later outlined four possible explanations for
inconsistencies between contemporaneously created medical records and later
testimony: (1) a person’s failure to recount to the medical professional everything that
happened during the relevant time period; (2) the medical professional’s failure to
document everything reported to her or him; (3) a person’s faulty recollection of the events
when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did
not exist. La Londe v. Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013),
aff’d, 746 F.3d 1335 (Fed. Cir. 2014).
The Court has also said that medical records may be outweighed by testimony that
is given later in time that is “consistent, clear, cogent, and compelling.” Camery, 42 Fed.
Cl. at 391 (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-2808, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998). The credibility of the individual offering
4

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 5 of 8
such testimony must also be determined. Andreu v. Sec’y of Health & Human Servs., 569
F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Human Servs., 991 F.2d
1570, 1575 (Fed. Cir. 1993).
IV. Analysis
Respondent contests Petitioner’s ability to establish that the residual effects of
his vaccine injury continued for more than six months, as required by the Vaccine Act.
Opp. at 5. Because Petitioner received his vaccination on September 23, 2019, he must
establish that his residual symptoms continued until at least March 23, 2020. Ex. 3 at
1.
The record clearly demonstrates that Petitioner sought treatment within 15 days of
his vaccination. Ex. 4 at 90-91. He had two appointments with his PCP, one x-ray, and
one appointment with an orthopedist in the next fifteen days, through October 30, 2019
(five weeks after his vaccination). Id. at 101, 131, 139, 167. Thereafter, there was a seven-
month gap (or until May 26, 2020) before Petitioner again sought treatment for his right
shoulder pain. Id. at 180-181. During this time, Petitioner received medical treatment only
on one occasion - March 10, 2020, for an infection in his finger. Id. at 197. After, there
was another gap of approximately three months, until September 5, 2020, before the next
report of shoulder pain. Id. at 197.
Petitioner argues that he has satisfied the statutory severity requirement because
he “sought regular treatment for his right shoulder pain through October 29, 2020, over
one year after his vaccine.” Mot. at 7. The medical records, however, reveal sporadic
rather than “regular,” treatment, with gaps of seven months, and then three months,
between appointments. The gap between initial presentation (which established some
SIRVA elements) and Petitioner’s March 2020 treatment is especially damaging to a
finding of severity.
Petitioner explained in a supplemental declaration that the gaps in treatment were
due to his work, which required him to “travel all over the country,” causing him to be
“typically home once a week,” and “unable to take any paid time off to visit the doctor.”
Ex. 7 at ¶4-5; Mot. at 9. He also stated that the doctor told him he ”could not do much
other than physical therapy or a hydrocortisone shot,” which he did not want. Ex. 7 at ¶4.
But a close review of the filed records does not support Petitioner’s claims.
First, Petitioner’s travel records indicate that he did seek care when he needed it
between work travel. For example, Petitioner had an appointment with his PCP on
October 30, 2019 (the day he left on travel), during which he received a refill of pain
medication for his shoulder pain. See Ex. 4 at 167; Ex. 8 at 26. He also had a medical
5

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 6 of 8
appointment on March 10, 2020, between travel ending March 8, 2020, and more travel
beginning on March 12, 2020. Ex. 4 at 180; Ex. 8 at 19, 30. Further, Petitioner was
traveling at the time he initially sought treatment for his shoulder pain - suggesting that if
his symptoms had continued, he would have continued to seek treatment despite his work
schedule. See Ex. 4 at 131 (x-ray on a travel day), 139-140 (orthopedist the day after
returning); 166 (appointment on a travel day); Ex. 8 at 8, 26. Finally, Petitioner did not
travel between November 12, 2019 and January 1, 2020, a period of seven weeks very
close in time to his vaccination – and he did not seek any treatment for his shoulder pain.
See Reply at 4. This record thus establishes that Petitioner found opportunities around
his travel to seek treatment for his shoulder pain, and could have continued to do so close
in time to his vaccination had it been necessary.
Second, Petitioner visited the doctor on March 10, 2020 for a right finger infection
– but did not at this time mention right shoulder pain. Ex. 4 at 180-181. Although
intervening medical appointments to address issues unrelated to a possible SIRVA are
often overlooked, or given less weight when evaluating whether claim elements are met,
the context here is different. As noted, Petitioner had taken time between travel to make
an appointment for an acute medical concern, suggesting he would likely have sought
care for his shoulder complaints had they still existed. At best, however, the relevant
record notes that Petitioner’s “active problem list” included adhesive capsulitis, but the
exam noted “no joint tenderness.” Id. Further, the relevant treater was his PCP, who had
provided care to Petitioner for shoulder pain in the past. Id.
In addition, Petitioner had made a point of mentioning his shoulder pain and
requested a medication refill at an appointment on October 30, 2019, when he saw his
PCP for other conditions, including skin and toenail problems. Ex. 4 at 166-167. Thus, if
Petitioner had continued to have right shoulder pain at the time of his March 10, 2020
appointment (very close to six months after his vaccination), he more likely than not would
have mentioned it to his PCP. The record overall supports the conclusion that Petitioner
was not one to avoid medical treatment when he felt it necessary – thereby supporting
the conclusion that he would have continued to seek treatment during the gap in treatment
if he was still experiencing sequelae.
Admittedly, Petitioner sought medical care for right shoulder pain on a few
occasions outside of or beyond the six-month period - specifically on May 26, 2020,
September 5, 2020, and October 29, 2020. In many cases, efforts to treat shoulder pain
complaints just beyond the severity timeframe allow the conclusion that the claimant was
still experiencing pain, even if he or she did not consistently seek treatment in the initial
six months from onset. Here, however, these instances of post-six months treatment do
not provide preponderant evidence that his symptoms at that time were a continuation of
his previous shoulder pain, and therefore, caused by his vaccination.
6

Case 1:21-vv-00549-TMD Document 36 Filed 02/01/24 Page 7 of 8
The appointment on May 26, 2020 with the orthopedist, for example, was by
telephone with no physical examination (although Petitioner did report improved range of
motion since his last visit). Ex. 4 at 197. The orthopedist recommended an in-person
evaluation, proposing that “given his resolution of stiffness, this could be cuff tendinitis
versus lingering pain from adhesive capsulitis.” Id. The orthopedist’s speculation suggests
that he believed there could be an alternative cause for Petitioner’s symptoms on that
date, but that an examination was necessary to make that determination. But Petitioner
did not return to his orthopedist again. Id.
The visits with Petitioner’s PCP on September 5, 2020 (more than three months
later) and October 29, 2020 (five months later) were also telemedicine appointments, with
no physical examination of Petitioner’s shoulder. Ex. 4 at 213, 250. At the September 5,
2020 appointment, the doctor does not appear to have made any assessment of
Petitioner’s shoulder, and only notes that Petitioner does not want to use anti-
inflammatory medications, including injections. Id. at 213-14. Again, the doctor
encouraged Petitioner to return if he continued to have symptoms. Id. at 214. And at the
final telemedicine visit on October 29, 2020, Petitioner reported that his shoulder pain had
been improving, but worsened again after sleeping on it. Ex. 4 at 251. The doctor
speculated that there was “potentially” impingement syndrome and recommended
continuing exercises and possibly a corticosteroid injection. Id. Petitioner did not follow
up.
Petitioner has stated that, as of February 21, 2023, he “continues to do stretches,
exercises and ice for [his] shoulder,” and has even purchased two new mattresses to try
to help with his pain. Ex. 7 at ¶6. But Petitioner’s supplemental declaration does not state
when he began those exercises, and the only evidence in the record to corroborate such
contentions is found in records from his October 29, 2020 appointment, which occurred
more than a year after vaccination. Ex. 4 at 250. There is simply insufficient evidence of
continuous symptoms from vaccination through at least March 23, 2020.
Given the above, I cannot conclude that Petitioner suffered the residual effects of
his vaccine-related injury for the six months required by the Act. The gaps in treatment,
coupled with Petitioner’s general pattern in seeking medical care between his work travel
when he deemed a health problem significant enough to warrant it, undermines the
conclusion that Petitioner’s symptoms continued through at least March 23, 2020.
7

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CONCLUSION
Because Petitioner has failed to meet the statutory severity requirement set forth
in Section 11(c)(1)(D)(i), Petitioner cannot establish entitlement and therefore, I must
DISMISS his claim in its entirety. The Clerk shall enter judgment in accord with this
Decision.4
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
4 If Petitioner wishes to bring a civil action, he must file a notice of election rejecting the judgment
pursuant to § 21(a) “not later than 90 days after the date of the court’s final judgment.”
8

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DOCUMENT 2: USCOURTS-cofc-1_21-vv-00549-1
Date issued/filed: 2024-05-31
Pages: 11
Docket text: JUDGE VACCINE REPORTED OPINION (PUBLIC VERSION) re: 40 Judge Vaccine Order/Opinion. Signed by Judge Thompson M. Dietz. (sbp) Service on parties made.
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Case 1:21-vv-00549-TMD Document 43 Filed 05/31/24 Page 1 of 11
In the United States Court of Federal Claims
No. 21-549
(Filed Under Seal: May 16, 2024)
(Reissued: May 31, 2024)1
**************************************
JARED TRINNAMAN, *
*
Petitioner, *
*
v. *
*
SECRETARY OF HEALTH AND HUMAN *
SERVICES, *
*
Respondent. *
**************************************
Laura Levenberg, Muller Brazil, Dresher, PA, counsel for Petitioner.
Eleanor A. Hanson, U.S. Department of Justice, Civil Division, Washington, DC, counsel for
Respondent.
OPINION AND ORDER
DIETZ, Judge.
Petitioner Jared Trinnaman (“Trinnaman”) seeks review of Chief Special Master
(“CSM”) Brian Corcoran’s decision denying him compensation under the National Childhood
Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 et seq. (“the Act”). Trinnaman alleges that he
suffered a shoulder injury related to vaccine administration (“SIRVA”) following an influenza
(“flu”) vaccine received on September 23, 2019. He sought compensation on January 11, 2021.
The CSM dismissed his petititon for compensation, concluding that he failed to meet the
statutory severity requirement set forth in Section 11(c)(1)(D)(i) of the Act. Trinnaman contends
that the CSM erred by making arbitrary and capricious findings of fact. Because Trinnaman has
not demonstrated that the CSM’s decision was arbitrary or capricious, the Court DENIES
Trinnaman’s motion for review and SUSTAINS the CSM’s decision.
1 Pursuant to Vaccine Rule 18(b) of the Rules of the United States Court of Federal Claims, the Court issued this
Opinion and Order under seal on May 16, 2024, and provided the parties fourteen days to propose redactions. See
[ECF 40]. The parties did not propose any redactions. Accordingly, the Court reissues this Opinion and Order
without redactions.

Case 1:21-vv-00549-TMD Document 43 Filed 05/31/24 Page 2 of 11
I. BACKGROUND2
Trinnaman “received the flu vaccine in his right deltoid at his primary care provider’s
(‘PCP’) office on September 23, 2019.”3 Trinnaman, 2023 WL 9477264, at *1. On October 8,
2019, during a telephone appointment with his PCP, Trinnaman complained of right shoulder
pain following the vaccine. Id. He further stated that although “he had tried ice and rest, . . . he
did not want to try medication for pain/inflammation, . . . .” Id. (internal quotation marks
omitted). He asked to schedule an in-person examination. Id.
On October 9, 2019, Trinnaman had an in-person visit with his PCP. Trinnaman, 2023
WL 9477264, at *1. At the appointment, Trinnaman stated that he had experienced pain since
receiving the vaccine and had “an inability to move his arm.” Id. (internal quotation marks
omitted). Upon examination, Trinnaman’s PCP found that “he had full passive range of motion
without pain, but [that he] reported pain with active range of motion.” Id. Triannaman’s PCP
offered him physical therapy. Id. During a telephone call with his PCP later that day, Trinnaman
“reported receiving the vaccination high in the right shoulder and [stated] that the pain was dull
aching to sharp at 8/10 if lifting.” Id. (internal quotation marks omitted). Also, during the
conversation, Trinnaman “insisted on x ray and seeing orthopedics, but declined an orthopedic
appointment the following day due to travel.” Id. (internal quotation marks omitted) (alteration to
original). He requested an orthopedic appointment on October 15, 2019. Id. On October 10,
2019, Trinnaman was x-rayed; the results were normal. Id.
During Trinnaman’s in-person appointment with an orthopedist on October 15, 2019, he
stated that his “shoulder pain and stiffness . . . was slowly getting better.” Trinnaman, 2023 WL
9477264, at *1 (internal quotation marks omitted). The orthopedist diagnosed Trinnaman with
adhesive capsulitis, recommended online phyiscal therapy, and suggested that he treat the pain
with ibuprofen instead of a narcotic medication. Id. The doctor further stated that he believed the
issue would “resolve on its own with more time.” Id. (internal quotation marks omitted).
On October 30, 2019, Trinnaman had an in-person visit with his PCP for “skin and
toenail complaints.” Trinnaman, 2023 WL 9477264, at *2. The doctor did not examine
Trinnaman’s shoulder during that visit but did refill his prescription for pain medication for his
right shoulder pain—acetaminophen with codeine. Id. Approximately five months later, on
March 10, 2020, Trinnaman again visited his PCP in person “for a right finger infection.” Id.
Trinnaman did not raise the issue of his shoulder during that visit. Id.
Trinnaman’s next appointment with his orthopedist was by telephone on May 26, 2020,
during which Trinnaman “stated that he continued to have pain with lifting and overhead
motion.” Trinnaman, 2023 WL 9477264, at *2. No examination was performed during this
appointment, and the doctor “speculated that [Trinnaman’s] symptoms could be rotator cuff
tendinitis or lingering pain from adhesive capsulitis.” Id. The orthopedist recommended an in-
person evaluation but did not believe that an MRI was necessary. Id.
2 The factual background is derived from the CSM’s decision. See Trinnaman v. Sec’y of Health & Hum. Servs.,
2023 WL 9477264 (Fed. Cl. Dec. 11, 2023).
3 Trinnaman was thirty-six years old when he received the vaccine. Trinnaman, 2023 WL 9477264, at *1.
2

Case 1:21-vv-00549-TMD Document 43 Filed 05/31/24 Page 3 of 11
On September 5, 2020, Trinnaman had a video appointment with his PCP for “rash, foot
pain, and skin and nail issues.” Trinnaman, 2023 WL 9477264, at *2. Although the doctor did
not examine Trinnaman’s shoulder during that appointment, he noted in Trinnaman’s medical
history that he had a “frozen shoulder resulting from a flu shot.” Id. (internal quotation marks
omitted). Further, the record from that visit indicated that Trinnaman did not want to be treated
with anti-inflammatories or cortisone injections for his right shoulder pain. Id. Trinnamen’s PCP
ordered blood work and x-rays at that time; Trinnaman’s bloodwork showed that his rheumatoid
factor was “slightly elevated.” Id.
Trinnaman next saw his PCP for right shoulder pain on October 29, 2020.4 Trinnaman,
2023 WL 9477264, at *2. During that visit—a video appointment—Trinnaman complained of
continued pain in his right shoulder. Id. He further stated that he was exercising but that he found
overhead movement painful. Id. The doctor noted that he “does appear to have full range of
motion of shoulders.” Id. (internal quotation marks omitted). The doctor recommended that
Trinnaman “continue exercises to maintain range of motion” and suggested “a cortisone injection
if there was no improvement.” Id. The last time Trinnaman saw his PCP was by video
appointment on December 16, 2020. Id. This appointment, however, was not for issues related to
his right shoulder, and there are no further references thereto in his medical records. Id.
Trinnaman sought compensation under the Act on January 11, 2021. Pet. [ECF 1]. He
alleged that he suffered “a Table Injury of SIRVA, resulting from the influenza vaccination
received on September 23, 2019.” Id. at 1.5 Based on a fully-briefed motion for a factual ruling
on the record, [ECFs 27, 28, 31], the CSM found that Trinnaman did not meet the Act’s statutory
severity requirement because he failed to demonstrate that he “suffered the residual effects of his
vaccine-related injury for the six months required by the Act.” Trinnaman, 2023 WL 9477264, at
*5. Therefore, on December 11, 2023, the CSM dismissed Trinnaman’s claim. Id. Trinnaman
sought review of the CSM’s decision on January 9, 2024. Pet.’s Mem. in Supp. of Mot. for
Review [ECF 34]. The government responded on February 6, 2024. Resp. [ECF 38]. The Court
held oral argument on May 9, 2024.
II. STANDARD OF REVIEW
This Court has jurisdiction under the Act to review a special master’s decision. 42 U.S.C.
§ 300aa-12(e)(2). In reviewing a special master’s decision, this Court may:
(A) uphold the findings of fact and conclusions of law of the special
master and sustain the special master’s decision, (B) set aside any of
the findings of fact or conclusions of law of the special master found
to be arbitrary, capricious, and abuse of discretion, or otherwise not
in accordance with law and issue its own findings of fact and
4 The CSM erroneously stated that Trinnaman’s October 2020 visit occurred on the thirtieth of the month. In the
upper right hand corner of the record from that visit, it states: “Visit date: 10/29/2020.” See, e.g., [ECF 8-3] at 250.
5 All page numbers in the petition for compensation, the medical records, and the parties’ briefings refer to the page
numbers generated by the CM/ECF system.
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conclusions of law, or (C) remand the petition to the special master
for further action in accordance with the court’s direction.
42 U.S.C. §§ 300aa-12(e)(2)(A)-(C).
This Court reviews a special master’s findings of fact under the “arbitrary and
capricious” standard, legal questions under the “not in accordance with law” standard, and
discretionary rulings under the “abuse of discretion” standard. Turner v. Sec’y of Health & Hum.
Servs., 268 F.3d 1334, 1337 (Fed. Cir. 2001). With respect to the arbitrary and capricious
standard, “no uniform definition . . . has emerged,” but it is “a highly deferential standard of
review” such that “[i]f the special master has considered the relevant evidence of record, drawn
plausible inferences and articulated a rational basis for the decision, reversible error will be
extremely difficult to demonstrate.” Hines v. Sec’y of Health & Hum. Servs., 940 F.2d 1518,
1527-28 (Fed. Cir. 1991); accord Motor Vehicle Mfrs. Ass’n of U.S., Inc. v. State Farm Mut.
Auto Ins. Co., 463 U.S. 29, 43 (1983) (a decision is arbitrary and capricious only if it is “so
implausible that it could not be ascribed to a difference of view”). The arbitrary and capricious
standard of review is difficult for an appellant to satisfy with respect to any issue, but particularly
with respect to an issue that turns on the weighing of evidence by the trier of fact. Lampe v. Sec’y
of Health & Hum. Servs., 219 F.3d 1357, 1360 (Fed. Cir. 2000). “[I]t is not . . . the role of this
court to reweigh the factual evidence, [] to assess whether the special master correctly evaluated
the evidence[, or to] . . . examine the probative value of the evidence or the credibility of the
witnesses.” Munn v. Sec’ of Dep’t of Health & Hum. Servs., 970 F.2d 863, 871 (Fed. Cir. 1992),
quoted in Lampe, 219 F.3d at 1360. “These are all matters within the purview of the fact finder.”
Id.
The “not in accordance with law” standard, on the other hand, is applied without
deference to legal determinations, such as “[w]hether the special master applied the appropriate
standard of causation . . . .” Deribeaux v. Sec’y of Health & Hum. Servs., 717 F.3d 1363, 1366
(Fed. Cir. 2013). Lastly, the abuse of discretion standard applies to the special master’s
evidentiary rulings, such as determinations regarding the qualification of experts and the
admissibility of their testimony. Piscopo v. Sec’y of Health & Hum. Servs., 66 Fed. Cl. 49, 53
(2005) (citing Kumho Tire Co. v. Carmichael, 526 U.S. 137, 152 (1999)). “The [abuse of
discretion standard] will rarely come into play except where the special master excludes
evidence.” Munn, 970 F.2d at 870 n.10; accord Caves v. Sec’y of Health & Hum. Servs., 100
Fed. Cl. 119, 131 (2011), aff’d, 463 F. App’x 932 (Fed. Cir. 2012).
The Federal Circuit has made clear that special masters, as the finders of fact, have the
responsibility to weigh the persuasiveness and reliability of evidence presented to them, and if
appropriate, the credibility of testimony. Moberly v. Sec’y of Health & Hum. Servs., 592 F.3d
1315, 1325 (Fed. Cir. 2010); see Terran v. Sec’y of Health & Hum. Servs., 195 F.3d 1302, 1316
(Fed. Cir. 1999) (“[T]he rules of evidence require that the trial judge determine whether the
testimony has a reliable basis in the knowledge and experience of [the relevant] discipline.”)
(internal quotation marks omitted). The special master has broad discretion in determining the
credibility of witnesses and weighing the evidence, and these credibility determinations are
“virtually unreviewable” by the reviewing court. Bradley v. Sec’y of Health & Hum. Servs., 991
F.2d 1570, 1575 (Fed. Cir. 1993). In other words, the reviewing court does not reweigh the
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evidence, assess whether the special master correctly evaluated the evidence, or examine the
probative value of the evidence or the credibility of the witnesses because all of these matters are
within the purview of the factfinder. Broekelschen v. Sec’y of Health & Hum. Servs., 618 F.3d
1339, 1349 (Fed. Cir. 2010) (citing Munn, 970 F.2d at 871); accord Loyd, Next Friend of C.L. v.
Sec’y of Health & Hum. Servs., No. 2022-1371, 2023 WL 1878572, at *2 (Fed. Cir. Feb. 10,
2023).
III. LEGAL STANDARDS
The Act was established to compensate individuals for a vaccine-related injury or death
after a showing that the vaccine caused that injury or death. 42 U.S.C. § 300aa-11(a)(5)(B)(10).
The Act provides two ways for a petitioner to establish causation. Munn, 970 F.2d at 865. First, a
petitioner may demonstrate causation through a statutorily prescribed presumption by showing
that the alleged injury meets the criteria listed on the Vaccine Injury Table (“Table”). 42 U.S.C.
§ 300aa-14. The Table identifies the covered vaccines, the corresponding injuries, and the time
period after vaccination in which the particular injuries must occur. 42 C.F.R. § 100.3 “[I]f a
petitioner can establish that [he] received a listed vaccine and experienced such symptoms or
injuries within the specified timeframes, [he] has met [his] prima facie burden to prove that the
vaccine caused [his] injuries.” de Bazan v. Sec’y of Health & Hum. Servs., 539 F.3d 1347, 1351
(Fed. Cir. 2008). Alternatively, if a petitioner suffered an injury listed on the Table but not within
the specified time period or if a petitioner suffered an “off-Table injury,” he must prove
“causation-in-fact” by a preponderance of the evidence.6 See 42 U.S.C. § 300aa-11(c)(1)(C)(ii);
see also Broekelschen, 618 F.3d at 1341-42.
Under the Table, a petitioner is considered to have suffered a SIRVA if he meets the
following criteria:
(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).
6 “This court has interpreted the ‘preponderance of the evidence’ standard referred to in the Vaccine Act as one of
proof by a simple preponderance, of ‘more probable than not’ causation.” Althen v. Sec’y of Health & Hum. Servs.,
418 F.3d 1274, 1279 (Fed. Cir. 2005) (citing Hellebrand v. Sec’y of Health & Hum. Servs., 999 F.2d 1565, 1572-73
(Fed. Cir. 1993)).
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42 C.F.R. 100.3(c)(10)(i)-(iv). In addition to satisfying the causation requirement, the petitioner
must also satisfy the statutory severity requirement, which mandates that the petitioner
demonstrate that he:
(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, . . . .
42 U.S.C.A. § 300aa-11(c)(1)(D)(i)-(iii). A petitioner must satisfy the requirements by a
preponderance of evidence. 42 U.S.C. § 300aa-13(a)(1). Further, the special master or court may
not find that a petitioner satifies the requirements based solely on the petitioner’s claims,
unsubstantiated by medical records or opinion. Id.
IV. ANALYSIS
In the instant case, the CSM dismissed Trinnaman’s claim, finding that he failed to
demonstrate that he “suffered the residual effects of his vaccine-related injury for the six
months” mandated by the Act’s severity requirement. Trinnaman, 2023 WL 9477264, at *5.
Trinnaman challenges the CSM’s decision, arguing that his factual findings were arbitrary and
capricious because he disregarded medical record evidence and testimony showing that the
SIRVA symptoms continued beyond six months after vaccination. [ECF 34] at 8. The
government maintains that the CSM did not commit reversible error and that his conclusions
were appropriately based on Trinnaman’s medical records, his statements, and his travel records.
[ECF 38] at 13-14. For the reasons stated below, the Court concludes that the CSM considered
the relevant medical records and testimony, drew plausible inferences, and articulated a rational
basis for his decision.
Trinnaman argues that the CSM “erroneously disregarded relevant and contemporaneous
recorded facts in the medical records that document [his] SIRVA symptoms lasting longer than
six months.” [ECF 34] at 8. In support of this contention, Trinnaman points to notes made by his
doctors following appointments in May, September, and October of 2020. Id. In Trinnaman’s
view, the notes are significant because they reflect that during his May and September 2020
visits, he attributed the pain in his shoulder to having received a flu shot. Id. (citing [ECF 8-3] at
197 (Dr. Anthony Lee Yu’s Notes from Trinnaman’s 5/26/2020 appointment); id. at 213 (Dr.
Victor Richard Fernandez’s Notes from Trinnaman’s 9/5/2020 appointment). According to
Trinnaman, these records demonstrate that the residual effects of his SIRVA “lasted longer than
both his initial course of treament in October of 2019 and his May 26, 2020 appointment with his
orthopedist.” [ECF 34] at 8-9. Next, Trinnaman contends that the CSM erroneously analyzed the
evidence regarding the severity of his SIRVA by neglecting to note that when Trinnaman visited
his doctor on March 10, 2020, for a right finger infection, he was also suffering from shoulder
pain. Id. at 9. Trinnaman avers: “The Vaccine Act does not require that a petitioner suffer
consistent symptoms throughout the six-month period post-vaccination, but instead only that a
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petitioner suffer the residual effects or complications of the alleged injury for more than six
months after administration of the vaccine.” Id. at 10. Thus, Trinnaman argues that “[t]he overall
record in this case shows [that he] suffered at least pain in his left shoulder range of motion until
as late as October 2020, more than one (1) year post-vaccination.” Id. (emphasis in original).
Trinnaman further argues that the CSM “erroneously disregarded relevant and
contemporaneous testimony from [him] that document [his] SIRVA symptoms lasting longer
than six months” and show that “a six-month gap in treatment [] was indisputably caused by the
prognosis given to him by his doctors combined with his work schedule.” [ECF 34] at 10. To
support this argument, Trinnaman points to his February 21, 2023, declaration. Id. at 10-11.
Therein, Trinnaman explains that the gap in his treatment was primarily due to his work schedule
and the diagnosis of his injury. [ECF 26-2] at 1. With respect to his work schedule, he states the
following:
I am an independent contractor that travels all over the country for
work. I am typically only home one day a week, making it very hard
to go to the doctor. Also, I can not [sic] take time off to make that
possible, as then I will not be paid for the week. I simply do not have
time to keep going back to the doctor to simply be told they can’t do
anything more to help me.
Id. Trinnaman included copies of emails and other materials documenting his work travel. See
[ECF 30-2]. Trinnaman also explains in his declaration that the “diagnosis that they could not do
much other than physical therapy or a hydrocortisone shot (which I’m told would be bad in the
long term) for my shoulder” also contributed to the gap in his treatment. [ECF 26-2] at 1.
Describing his condition, Trinnaman states that he is “still dealing with the painful shoulder and
[an] inability to perform certain tasks at work, due to [his] shoulder, on a daily basis.” Id.
The Court finds that Trinnaman has not demonstrated that the CSM’s consideration of
either his medical records or his testimony was arbitrary or capricious. In the factual background
section of his decision, the CSM discussed Trinnaman’s May, September, and October 2020
appointments. Trinnaman, 2023 WL 9477264, at *2. Regarding the May 26, 2020, appointment,
the CSM noted that it was a telephone appointment with Trinnaman’s orthopedist and that
Trinnaman complained of continued pain associated with “lifting and overhead motion.” Id. The
CSM further noted that “[n]o examination was performed” and that “[t]he doctor speculated that
[his] symptoms could be rotator cuff tendinitis or lingering pain from adhesive capsulitis [(a
diagnosis related to his shoulder)], and recommended an in-person evaluation.” Id. Regarding the
September 5, 2020, appointment, the CSM noted that it was a video appointment with
Trinnaman’s PCP for “a rash, foot pain, and skin and nail issues.” Id. The CSM continued,
stating that Trinnaman’s “medical history referenced ‘frozen shoulder resulting from a flu shot,’”
that no examination was performed, and that Trinnaman “wanted to avoid anti-inflammatories,
including cortisone injections, for his right shoulder pain.” Id. Regarding the October 29, 2020,
appointment, the CSM noted that it was a video appointment for “continued right shoulder pain,”
and that Trinnaman “stated he was ‘doing some exercises . . . but continues with some pain,’
particularly with overhead movement.” Id. (quoting [ECF 8-3] at 250). The CSM further noted
that Trinnaman’s medical record stated that he “appear[ed] to have full range of motion of
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shoulders,” id. (quoting [ECF 8-3] at 251) (internal quotation marks omitted), and that “[t]he
doctor recommended that he continue exercises to maintain range of motion, and possibly, a
cortisone injection if there was no improvement,” id. (citing [ECF 8-3] at 251).
In his analysis, which follows his recitation of the facts, the CSM explained why he
concluded that the residual symptoms of Trinnaman’s SIRVA did not continue until March 23,
2020—six months after he received the vaccine. Trinnaman, 2023 WL 9477264, at *3. Citing
Trinnaman’s medical records, the CSM noted that Trinnaman only sought sporadic treatment for
his injury: “The medical records, [], reveal sporadic rather than ‘regular,’ treatment, with gaps of
seven months,7 and then three months,8 between appointments.” Id. According to the CSM,
“[t]he gap between initial presentation (which established some SIRVA elements) and
Petitioner’s March 2020 treatment is especially damaging to a finding of severity.” Id. In
reaching this conclusion, the CSM considered Trinnaman’s supplemental declaration, wherein
Trinnaman explains that because he is obliged to “travel all over the country,” for work, he is
“typically home once a week,” and “unable to take any paid time off to visit the doctor.”
Trinnaman, 2023 WL 9477264, at *4 (quoting [ECF 26-2] at 1) (internal quotation marks
omitted). In the CSM’s view, Trinnaman’s travel records demonstrated that Trinnaman’s work
schedule did not hinder his ability to seek medical care because he was able to make his
appointments between his work trips. Id. In support of his conclusion, the CSM cited multiple
doctors’ appointments scheduled by Trinnaman on travel days and days in between travel days:
“This record thus establishes that Petitioner found opportunities around his travel to seek
treatment for his shoulder pain, and could have continued to do so close in time to his
vaccination had it been necessary.” Id. (emphasis in original).
The CSM also specifically considered Trinnaman’s doctor visit on March 10, 2020, for a
right finger infection, which occurred “very close to six months after his vaccination.”
Trinnaman, 2023 WL 9477264, at *4. The CSM concluded that Trinnaman’s effort to seek
medical care for a finger infection between travel suggests that he would have sought care for
shoulder pain had it still existed. Id. The CSM acknowledged that the relevant medical record
notes “adhesive capsulitis” as an active problem but still concludes that the record does not show
that Trinnaman identified shoulder pain as a reason for this visit. Id. The CSM determined that
“[t]he record overall supports the conclusion that [Trinnaman] was not one to avoid medical
treatment when he felt it necessary . . . [and] that he would have continued to seek treatment
during the gap in treatment if he was still experiencing sequelae” from his vaccination. Id.
Lastly, the CSM considered Trinnaman’s medical appointments on May 26, 2020,
September 5, 2020, and October 29, 2020 and concluded—based on his review of the medical
records—that although Trinnaman “sought medical care for right shoulder pain on a few
occasions outside of or beyond the six-month period . . . these instances d[id] not provide
preponderant evidence that his symptoms at that time were a continuation of his previous
shoulder pain, and therefore caused by his vaccination.” Trinnaman, 2023 WL 9477264, at *4
7 Seven months lapsed between Trinnaman’s October 30, 2019, appointment and his May 26, 2020, appointment.
Trinnaman, 2023 WL 9477264, at *3.
8 Approximately three months lapsed between Trinnaman’s May 26, 2020, appointment and his September 5, 2020,
appointment. Trinnaman, 2023 WL 9477264, at *3.
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(emphasis in original). In reaching this conclusion, the CSM revisited the medical records for
each appointment and explained that, due to the lack of a physical examination of Trinnaman’s
shoulder and the speculation in the medical records by Trinnaman’s doctors that the shoulder
pain at the time of these appointments could have alternative causes, “[t]here is simply
insufficient evidence of continuous symptoms from vaccination through at least March 23,
2020.” Id. at *5. In sum, the CSM’s determination that Trinnaman failed to demonstrate that he
suffered the residual effects of his vaccine-related injury for six months as required by the Act
was based upon his consideration of the relevant evidence and his plausible inferences drawn
therefrom. See Hines, 940 F.2d at 1527-28. It is not the Court’s role to reweigh the evidence or to
assess whether the CSM correctly evaluated the evidence. Broekelschen, 618 F.3d at 1349.
With respect to the medical appointments that took place on May 26, 2020, September 5,
2020, and October 29, 2020, Trinnaman argues that the CSM “improperly disregarded specific,
contemporaneously-quoted details in [his] medical records [that describe] continuing SIRVA
symptoms more than six months after his vaccination.” [ECF 34] at 8. While Trinnaman is
correct that the CSM’s decision does not recite each portion of the medical records that reference
his shoulder pain after his flu shot, this does not necessarily mean that the CSM disregarded the
medical records or that his conclusions were arbitrary or capricious. To the contrary, the CSM
expressly acknowledged in his decision that Trinnaman “sought medical care for right shoulder
pain” beyond the six-month period. Trinnaman, 2023 WL 9477264, at *4. Thus, while the
decision does not explicitly recite all pertinent portions of the medical records, the CSM clearly
reviewed the medical records and understood that these appointments related to shoulder pain.
Further, the CSM acknowledged that “[i]n many cases, efforts to treat shoulder pain complaints
just beyond the severity timeframe allow the conclusion that the claimant was still experiencing
pain, even if he or she did not consistently seek treatment in the initial six months from onset.”
Id. Thus, the CSM recognized that Trinnaman need not have suffered consistent symptoms
throughout the six-month period post-vaccination to satisfy the statutory severity requirement.
The Court cannot say that the CSM’s conclusion—that Trinnaman’s shoulder pain at the time of
these appointments was not a residual effect of his vaccination—is so implausible as to be
arbitrary or capricious. See Motor Vehicle Mfrs. Ass’n of U.S., 463 U.S. at 43 (a decision is
arbitrary and capricious only if it is “so implausible that it could not be ascribed to a difference
of view”).
Citing to the United States Court of Appeals for the Federal Circuit’s reasoning in Kirby
v. Secretary of Health and Human Services, 997 F.3d 1378 (Fed. Cir. 2021), Trinnaman also
argues that the CSM improperly inferred that Trinnaman was not suffering shoulder pain when
he visited his PCP on March 10, 2020, for a right finger infection because the medical record
from that appointment does not mention shoulder pain. See [ECF 34] at 8. However,
Trinnaman’s reliance on Kirby is misplaced. In Kirby, the United States Court of Federal Claims
(“CFC”) reversed the Special Master’s ruling, holding that because the petitioner’s medical
records were “silent about her vaccine injury and indicate[d] she was ‘feeling fine,’ [during the
six months following her vaccination,] they undermine[d] her testimony that she continued to
experience symptoms during this period.” 997 F.3d at 1382. The Federal Circuit then reversed
the CFC’s ruling, holding that the Special Master’s conclusion that petitioner’s vaccine injury
lasted more than six months was based on plausible evidence that included petitioner’s “lay
testimony, corroborating documentation, and expert testimony.” Id. at 1381. The Federal Circuit
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found that the CFC erroneously presumed that Kirby’s medical records were accurate and
complete: “The Claims Court reasoned that because Ms. Kirby’s medical records from January
2014 through July 2015 are silent about her vaccine injury and indicate she was ‘feeling fine,’
they undermine her testimony that she continued to experience symptoms during this period.” Id.
at 1382. The Federal Circuit explained:
We reject as incorrect the presumption that medical records are
accurate and complete as to all the patient’s physical conditions.
Although a patient has a “strong motivation to be truthful” when
speaking to his physician, see Fed. R. Evid. 803 advisory
committee’s note to 1975 enactment, that does not mean he will
report every ailment he is experiencing, or that the physician will
accurately record everything he observes. A patient having a heart
attack is not likely to mention his runny nose, nor is his physician
likely to record it. As the Claims Court has recognized, physicians
may enter information incorrectly and “typically record only a
fraction of all that occurs.” Shapiro v. Sec’y of Health & Human
Servs., 101 Fed. Cl. 532, 538 (2011) (citing Murphy v. Sec’y of
Health & Human Servs., 23 Cl. Ct. 726, 733 (1991)). We see no
basis for presuming that medical records are accurate and complete
even as to all physical conditions.
Id. at 1383. Significantly, the Federal Circuit did not conclude that when a petitioner’s medical
records are silent as to his condition, the petitioner’s testimony should necessarily be credited or
given more weight. Rather, the court held that “[b]ecause a reasonable fact finder could
conclude that Ms. Kirby’s testimony is not inconsistent with her medical records from January
2014 through July 2015, it was not arbitrary and capricious for the special master to credit that
testimony in finding that Ms. Kirby’s vaccine injury lasted more than six months.” Id. at 1384
(emphasis added). In other words, the court found that because it was neither arbitrary nor
capricious for the fact finder—the Special Master—to conclude that the medical records did not
paint the entire picture and that the petitioner’s testimony was credible, the Special Master’s
ruling should be upheld. Here, there is no indication that the CSM presumed that the March 10,
2020, medical record was accurate and complete and thereby excluded the possibility that
Trinnaman was still experiencing shoulder pain. Instead, the CSM analyzed the medical record
and determined that, despite its reference to adhesive capsulitis as an active problem, the
appointment was for a right finger infection, not continued treatment for shoulder pain. See
Trinnaman, 2023 WL 9477264, at *4. The CSM then concluded that the March 10, 2020, record
“supports the conclusion that [Trinnaman] was not one to avoid medical treatment when he felt it
necessary – thereby supporting the conclusion that he would have continued to seek treatment
during the gap in treatment if he was still experiencing sequelae.” Id. This is a plausible
inference drawn from the medical record—an inference that is not precluded by the Federal
Circuit’s holding in Kirby. The Court finds that the CSM’s consideration of the evidence
(Trinnaman’s medical records, Trinnaman’s documentation of his work travel, and Trinnaman’s
declaration), the CSM’s conclusion that Trinnaman’s SIRVA did not meet the Act’s statutory
severity requirement, and the CSM’s explanation of the reasoning behind his conclusion were all
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rational.9 See Kirby, 997 F.3d at 1381-82 (stating that the evidence, “considered in light of the
record as a whole” is sufficient for the special master’s finding to stand, when that finding is
based on plausible evidence). The Court will not second guess the CSM’s evaluation of the
evidence. See Hodges v. Sec’y of Health & Hum. Servs., 9 F.3d 958, 961 (Fed. Cir. 1993)
(expressing that the Act “makes clear” that the reviewing court’s purpose “is not to second guess
the Special Master[’]s fact-intensive conclusions”).
V. CONCLUSION
Trinnaman has not demonstrated that the CSM’s decision was arbitrary, capricious, an
abuse of discretion, or otherwise not in accordance with law. Therefore, Trinnaman’s motion for
review of the CSM’s decision [ECF 33] is DENIED, and the CSM’s entitlement decision of
December 11, 2023, is SUSTAINED. The Clerk of the Court is DIRECTED to enter judgment
accordingly.
IT IS SO ORDERED.
s/ Thompson M. Dietz
THOMPSON M. DIETZ, Judge
9 Trinnaman also argues that the facts in his case are analogous to the facts in Silvestri v. Secretary of Health and
Human. Services, 2021 WL 4205313 (Fed. Cl. Spec. Mstr. Aug. 16, 2021), where the CSM found that the
petititioner had satisfied the statutory severity burden. [ECF 43] at 12-13. While these cases are similar in some
respects, the Court finds two distinguishing features. In Silvestri, the CSM found that the medical records
demonstrated that the petititioner “consistently sought treatment for his left shoulder injury” in the five months
immediately following his vaccination. Silvestri, 2021 WL 4205313, at *3. By comparison, in the instant case, the
CSM found that Trinnaman’s medical records post vaccination “reveal[ed] sporadic rather than ‘regular[]’
treatment, with gaps of seven months, and then three months, between appointments.” Trinnaman, 2023 WL
9477264, at *3. Additionally, with respect to the gap in treatment, the CSM in Silvestri found that the petitioner
“provided a credible explanation of why he did not seek additional care for his injury” after five months elapsed post
vaccination and that a “number of facts better support Petitioner’s position on severity.” Silvestri, 2021 WL
4205313, at *3-4. In this case, the CSM found that Trinnaman’s explanations for the gap in treatment are
unsupported by the record. Trinnaman, 2023 WL 9477264, at *4 (“But a close review of the filed records does not
support Petitioner’s claims.”). As the finder of fact, the special master is responsible for weighing the persuasiveness
and reliability of the evidence, Moberly, 592 F.3d at 1325, and reversible error is difficult to demonstrate if the
special master considered the relevant evidence, drew plausible inferences therefrom, and articulated a rational basis
for the decision, Lampe, 219 F.3d at 1360.
11