Antonio J. Smith v. HHS - Influenza, shoulder injury related to vaccine administration (SIRVA) (2024)

Antonio J. Smith, born in 1981, filed a petition for compensation under the National Vaccine Injury Compensation Program on February 18, 2021.

He alleged that he suffered a shoulder injury related to vaccine administration (SIRVA) as a result of an influenza vaccine administered on November 5, 2019. The case was assigned to the Special Processing Unit.

The respondent initially filed a report recommending denial of entitlement. Following briefing by both parties, Chief Special Master Brian H.

Corcoran issued a ruling on entitlement on June 27, 2024. Mr.

Smith, who was incarcerated at the Wisconsin Secure Program Facility at the time of vaccination, received the flu vaccine in his left deltoid. On the same day, he reported pain at the injection site.

Medical records from November 6, 2019, noted slight swelling in his left arm, and subsequent records documented ongoing left shoulder pain, stiffness, and decreased range of motion. Dr.

Eileen Gavin noted the history of left shoulder injury since the vaccine and questioned if a pre-existing condition was exacerbated. A physical therapy evaluation on December 16, 2019, confirmed left-sided weakness, decreased range of motion, and "frozen shoulder." By March 4, 2020, Dr.

Tricia Lorenz assessed Mr. Smith with tendinitis and impingement syndrome.

In June 2020, Dr. Michael Gross repeated these assessments and noted unremarkable x-ray findings.

Mr. Smith resumed physical therapy in July 2020, with assessments of adhesive capsulitis.

In September 2020, Dr. Edward Riley evaluated Mr.

Smith, noting decreased range of motion and weakness in the left shoulder, with normal neurological findings, and also noted neck pain. MRIs in January 2021 showed supraspinatus tendinosis and mild acromioclavicular osteoarthritis in the left shoulder, and degenerative changes with foraminal narrowing in the cervical spine.

By February 2021, Mr. Smith's range of motion had objectively improved, and he was no longer suffering from adhesive capsulitis.

By April 8, 2021, his pain location shifted to his neck, and his left shoulder had full strength and range of motion, though passive rotation was somewhat limited. He was discharged from physical therapy on that date.

In February 2022, Dr. Justin Ribault noted limited left neck rotation, limited left shoulder abduction, poor internal rotation, and pain with left trapezius palpation, suggesting a left trapezius strain and noting that the shoulder complaint did not fully match MRI abnormalities.

Dr. Ribault also noted that Mr.

Smith had a stable left shoulder decreased range of motion along with localized pain since at least 2018, a notation the Special Master found inconsistent with the overall weight of medical records. In November 2022, Dr.

Riley re-evaluated Mr. Smith, assessing cervical spondylosis with nerve root impingement and left upper extremity weakness, and chronic left shoulder pain and limited motion, possibly a sequela of frozen shoulder, recommending evaluation for left upper extremity weakness before proceeding with shoulder treatment.

The Special Master found that Mr. Smith had preponderantly established entitlement to compensation for a Table SIRVA, determining that he met the criteria, including no history of prior shoulder pain that would explain the symptoms and no other condition explaining the symptoms, such as a trapezius strain.

The case is proceeding to the damages phase. The Special Master tentatively assessed damages to extend at least until April 8, 2021, and encouraged the parties to reach a compromise on pain and suffering.