VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_23-vv-00238
Package ID: USCOURTS-cofc-1_23-vv-00238
Petitioner: Lee Yuill
Filed: 2025-07-31
Decided: 2025-09-03
Vaccine: influenza
Vaccination date: 2020-10-14
Condition: left shoulder injury related to vaccine administration (SIRVA)
Outcome: entitlement_granted_pending_damages
Award amount USD: 

AI-assisted case summary:
Lee Yuill filed a petition for compensation under the National Vaccine Injury Compensation Program, alleging he suffered a left shoulder injury related to vaccine administration (SIRVA) following an influenza vaccine received on October 14, 2020. The administration record did not specify the injection site, but Mr. Yuill consistently reported pain in his left arm or shoulder, attributing it to the vaccine, starting about two weeks after administration. He sought treatment, including physical therapy, which provided some relief, but he continued to experience pain and soreness. Although there was a gap in formal treatment for about six months, Mr. Yuill stated he continued self-treatment and provided life events as reasons for not seeking further medical care during that period. Upon returning to treatment, he again linked his pain to the flu shot. Medical records showed various diagnoses and treatments, including physical therapy, orthopedic evaluations, and surgery, with some findings of degenerative changes and tears in the shoulder. Respondent argued that the injury did not last for the required six months and that the vaccination site was not definitively proven to be the left arm. However, the Special Master found that Mr. Yuill more likely than not received the vaccine in his left arm, based on his consistent reporting. The Special Master also found that the residual effects of the injury lasted for more than six months, considering his continued self-treatment, reasonable explanation for the treatment gap, and ongoing medical interventions that addressed shoulder pain. As this was a Table SIRVA claim, causation was presumed. The Special Master ruled that Mr. Yuill is entitled to compensation, with a separate damages order to be issued.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_23-vv-00238-0
Date issued/filed: 2025-09-03
Pages: 8
Docket text: PUBLIC ORDER/RULING (Originally filed: 07/31/2025) regarding 24 Ruling on Entitlement, Order on Motion for Ruling on the Record. Signed by Chief Special Master Brian H. Corcoran. (cr) Service on parties made.
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Case 1:23-vv-00238-UNJ Document 27 Filed 09/03/25 Page 1 of 8
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-0238V
LEE YUILL, Chief Special Master Corcoran
Petitioner, Filed: July 31, 2025
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for Respondent.
RULING ON ENTITLEMENT1
On February 17, 2023, Lee Yuill filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). ECF No. 1. Petitioner alleges that he suffered a left shoulder injury related
to vaccine administration (“SIRVA”) following an influenza ("flu”) vaccine received on
October 14, 2020. Petition at 1. The case was assigned to the Special Processing Unit of
the Office of Special Masters.
For the reasons set forth below, I find that Petitioner more likely than not received
the flu vaccine in his left arm, and more likely than not suffered the residual effects of his
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 1:23-vv-00238-UNJ Document 27 Filed 09/03/25 Page 2 of 8
alleged vaccine-related injury for more than six months. Therefore, and because
Respondent does not contest the other requirements of a Table SIRVA claim, Petitioner
is entitled to compensation under the Vaccine Act.
I. Relevant Procedural History
On December 20, 2023, just over 10 months after the case was initiated,
Respondent his Rule 4(c) Report in which he argued that, based on the medical records,
Petitioner had not provided sufficient evidence that the residual effects of that injury lasted
for at least six months. ECF No. 18.
On February 9, 2024, Petitioner filed a motion for a Ruling on the Record
Regarding Entitlement (“Mot.”). ECF No. 19. Respondent filed a response (“Resp.”) on
March 25, 2024, in which he reiterates his previous argument that Petitioner has not
satisfied the statutory severity requirement and also added, for the first time, an argument
regarding the site of vaccination. ECF No. 22. The matter is now ripe for adjudication.
II. Factual History
Petitioner received a flu vaccine on October 14, 2020, at his employer’s facility in
Alabama. Ex. 1 at 3. The administration record does not indicate the site of vaccination.
Id. About two weeks later, Petitioner visited a new primary care provider (“PCP”) on
October 29, 2020. Ex. 8 at 23. The record indicates that Petitioner declined a flu shot
because he had already received one for that season. Id. He also reported that his left
arm was sore. Id. at 24.
On December 1, 2020, Petitioner had email correspondence with the director of
employee health at Huntsville Hospital. Ex 3. Petitioner stated that he received a “flu shot
back on Oct 14 th (sic)” and that he was “still experiencing some arm pain in [his] left arm
bicep area where the shot was given.” Id. at 2. Petitioner saw an employee health
physician two days later with complaints of “normal pain after [the] shot,” that “never went
away.” Ex. 4 at 4. He was referred to physical therapy. Id.
Petitioner began physical therapy on December 15, 2020. Ex. 5 at 18. He reported
that he “received a flu shot (10/14/20) in his left shoulder and has been experiencing pain
ever since.” Id. He had a total of seven physical therapy treatments through January 5.
2021. Id. at 4-14. Upon discharge, Petitioner had met his therapy goals and reported that
his “pain from the flu shot had mostly resolved,” but he continued to have soreness in the
shoulder and his mobility was “improving.” Id. at 14, 17. He was given a home exercise
plan. Id. at 14.
Petitioner stated that after finishing physical therapy, he continued to self-treat his
shoulder pain with ice, heat, compression sleeves, stretches and exercises, a massage
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gun, CBD cream, kinesiology tape, and over-the-counter medications, which provided
temporary relief. Ex. 11 at ¶5. He recalled pain continuing to wake him from sleep, but
that certain events during the spring of 2021 prevented him from prioritizing medical
treatment. Id. at ¶6-7. Petitioner noted work obligations in January 2021, home building
beginning in February 2021, and a serious car accident involving his wife in April 2021.
Id. at ¶7.
Petitioner returned to employee health on July 14, 2021 – approximately six
months after his previous treatment. Ex. 4 at 7. He reported pain and weakness in his left
upper arm “from the site of his flu shot last November.” Id. No physical examination was
noted in the record, and he was referred to a neurologist. Id.
Petitioner saw a neurologist on July 29, 2021. Ex. 6 at 10. He reported that “within
the first few days” after his “flu vaccination in his left deltoid” he had muscle tenderness
that was aggravated by movement. Id. He reported constant, moderate pain that
worsened with movement. Id. On exam, he had “some limited range of motion,” but had
“both proximal and distal strength intact.” Id. at 13. He also had some findings suggestive
of cervical pathology or possibly cardiac causes. Id. A cervical MRI and EMG were
ordered, and a cardiology evaluation recommended. Id. The MRI revealed “multilevel
degenerative changes, most significant at C6-7 where there is moderate right and mild to
moderate left neuroforaminal narrowing.” Id, at 3-4. The EMG was normal. Id. at 9.
On September 15, 2021, Petitioner returned to employee health for further
treatment for his “persistent” left shoulder pain. Ex. 4 at 10. He stated “that this all started
after receiving the flu vaccine.” Id. The doctor noted that although his MRI showed some
degenerative changes, the doctor felt this was “not a good explanation for his pain.” Id.
She noted that his pain “is very specially L lower deltoid and some pain at his lower bicep
region,” and referred Petitioner to an orthopedist. Id.
Petitioner saw an orthopedic surgeon the following day. Ex. 7 at 29. He reported
shoulder pain that “started after a flu shot was administered by a student on October 14,
2020.” Id. He was diagnosed with impingement and adhesive capsulitis and sent for an
MRI, which revealed a “partial thickness interstitial tear of the supraspinatus, a tear of the
posterosuperior and inferior labrum, and tendinosis of the infraspinatus.” Id. at 30-31, 40-
41. Petitioner returned on October 1, 2021 for a follow-up visit, during which he was given
a steroid injection and referred back to physical therapy. Id. at 26-27.
Petitioner returned to physical therapy for an evaluation on October 6, 2021. Ex. 7
at 104. He reported that “he had the flu shot and then his shoulder began to have some
pain.” Id. He completed a total of ten physical therapy sessions through November 23,
2021 and was discharged to a home exercise program. Id. at 75 – 103. Upon discharge,
the therapist noted that Petitioner was “moving well overall and is functional”. Id. at 75.
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Petitioner continued to treat his left shoulder pain, including with surgery, through
mid-2022.
III. Applicable Legal Standards
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
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
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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
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).
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 & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within
the special master's discretion to determine whether to afford greater weight to medical
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).
IV. Finding of Fact
A. Situs of Vaccination
Although Petitioner’s vaccination record is silent as to the administration situs, he
was consistent in attributing his shoulder pain to his vaccination whenever he obtained
treatment. With his first communication to his employer regarding this shoulder pain,
Petitioner attributed pain in his left arm to his vaccination.3 See Ex. 3. Petitioner continued
to link his shoulder pain to the vaccination throughout the remainder of his treatment,
including with an employee health physician, two physical therapists, and an orthopedic
surgeon. See e.g., Ex. 4 at 4; Ex. 5 at 18; Ex. 6 at 10; Ex. 7 at 29. Petitioner never
complained of, or received treatment for, right shoulder pain.
Given that the initial vaccine administration record is silent on the issue of situs,
this is not a case where a testimonial assertion on the disputed fact seeks to vary or
3 Petitioner also mentioned both his flu shot and left arm pain to his PCP during a visit only 15 days after
vaccination, but the record is not clear exactly what he reported. Although not sufficiently specific, this
record does not contradict Petitioner’s allegation of administration in the left arm. See Ex. 8 at 23-24.
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negate a record’s content. Thus, though it is well-settled that “oral testimony in conflict
with contemporaneous documentary evidence deserves little weight,” such testimony can
be credited where it provides detail that the record omits. Kirby, 997 F.3d at 1383
(emphasis added). Here, Petitioner’s statements about the vaccination do not conflict with
the vaccine administration record, but provide information that was not recorded at the
time of the vaccine or for which other documentary evidence is not available. And
otherwise there is no evidence in the record that Petitioner received the vaccine in his
right arm.
I therefore find it more likely than not that the vaccine alleged as causal in this case
was administered to Petitioner in the left shoulder on October 14, 2020.
B. Severity
To satisfy the statutory severity requirement, Petitioner must demonstrate that his
symptoms more likely than not continued until at least April 14, 2021 (six months from the
October vaccination). There is no dispute that Petitioner sought treatment for his left
shoulder pain through the end of his first course of physical therapy on January 6, 2021
– and then did not seek further treatment until July 14, 2021, six months later. Mot. at 2-
3; Resp. at 2-3. Respondent argues that Petitioner reported that his pain was “mostly
resolved” at the end of his initial physical therapy treatment and was able to perform his
activities of daily living at the time – suggesting that his future complaints were not related
to his flu vaccination. Resp. at 5-6. He further argues that concerns during Petitioner’s
later treatment for cervical issues also suggests that his return to treatment was not
related to his initial injury – and thus fails to satisfy the six-month severity requirement. Id.
at 6-7.
Although Petitioner did not seek treatment for a six-month period that overlaps with
the six-month severity date, there is evidence that preponderates in favor of severity being
met. First, when Petitioner returned to treatment in July 2021, he directly related his pain
back to his prior vaccination, and he continued to do so throughout his ongoing treatment.
Ex. 4 at 7; See also Ex. 5 at 18; Ex. 6 at 10; Ex. 7 at 29. Further, Petitioner continue to
have some shoulder symptoms at the end of his first physical therapy treatment –
including soreness, tightness, and limited mobility – even though his symptoms were
much improved. See Ex. 5 at 14, 17. There is no evidence that Petitioner’s shoulder
symptoms have fully resolved prior to the gap in treatment.
In addition, Petitioner stated in his declaration that he continued to treat ongoing
symptoms at home during the gap in formal treatment, utilizing ice, heat, compression
sleeves, stretches and exercises, a massage gun, CBD cream, kinesiology tape, and
over-the-counter medications, which provided only temporary relief. Ex. 11 at ¶5. And
Petitioner has provided a reasonable explanation for why he did not return to formal
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treatment, even though he continued to have shoulder pain. Specifically, Petitioner noted
three life events that “pushed [his] shoulder symptoms to the bottom of [his] priority list”
during the gap in treatment: work recruitment requirements, building a home, and a
serious car accident involving his wife. Id. at ¶7.
Respondent’s next argument – that the fact that Petitioner received neurological
testing and investigation of cervical symptoms, which severed any connection to his
vaccination – is likewise unpersuasive. First, Petitioners often undergo neurological
testing during SIRVA treatment – but Petitioner’s EMG was negative (and thus
unsupportive of an alternative explanation for his complaints). See Ex. 6 at 9. Further,
even though some degenerative findings were revealed in Petitioner’s cervical MRI at the
time, his doctors felt that those findings were “not a good explanation for his pain,” and
continued to offer targeted orthopedic care for his shoulder pain, including a shoulder
MRI, additional physical therapy, steroid injections, and surgery. See Ex. 4 at 10; Ex. 7.
The fact that Petitioner was later (long after his shoulder surgery) diagnosed with a
cervical condition, as Respondent notes, does not negate the fact that he more likely than
not suffered from his left shoulder pain for more than six months after his vaccination.
Thus, after consideration of the entire record, which includes both medical records
and witness testimony, I find that Petitioner has provided preponderant evidence that the
residual effects of his vaccine-related injury lasted for at least six months.
V. Ruling on Entitlement
a. Requirements for Table SIRVA
Other than the argument above regarding the site of vaccination, Respondent has
not contested Petitioner’s proof on the specific elements of a Table SIVRA. In light of
Respondent’s position and the evidence of record, I find that Petitioner has provided
preponderant evidence to establish that he suffered a Table SIRVA injury.
b. Additional Requirements for Entitlement
Because Petitioner has satisfied the requirements of a Table SIRVA, he need not
prove causation. Section 11(c)(1)(C). However, he must satisfy the other requirements of
Section 11(c) regarding the vaccination received, the duration and severity of injury, and
the lack of other award or settlement. Section 11(c)(A), (B), and (D).
The vaccine record shows that Petitioner received his vaccination on October 14,
2020 in Alabama. Ex. 1 at 3; Section 11(c)(1)(A) (requiring receipt of a covered vaccine);
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Section 11(c)(1)(B)(i) (requiring administration within the United States or its territories).
Additionally, Petitioner has stated that he has not filed any civil action or received any
compensation for his vaccine-related injury, and there is no evidence to the contrary. Ex.
11 at ¶8; See Section 11(c)(1)(E) (lack of prior civil award). And as noted above, I find
that the severity requirement has been established. See Section 11(c)(1)(D)(i) (statutory
six-month requirement). Therefore, Petitioner has satisfied all requirements for
entitlement under the Vaccine Act.
Conclusion
Based on the entire record in this case, I find that Petitioner has provided
preponderant evidence satisfying all requirements for a Table SIRVA. Petitioner is
entitled to compensation in this case. A separate damages order will be issued.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
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