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Ep 248 - SIRVA:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

An older man holding his shoulder while a physical therapist assists him.

A 75-year-old client has had several vaccines for COVID and other infections over the last 9 months, and now she has pain, weakness, and limited range of motion in both shoulders. Typical massage appears to make it worse. What is happening, and what can we do about it?


Pocket Pathology:

Minimally Invasive Treatments & Alternatives to Orthopedic Surgery (no date) Boston Sports. Available at: (Accessed: 3 June 2022).

"Rare and Preventable: Painful Post-vax Shoulder Problems" (no date) Medscape. Available at: (Accessed: 6 June 2022).

Starkman, E. (no date) "What Is SIRVA?", WebMD. Available at: (Accessed: 3 June 2022).

Wood, C.T. and Ilyas, A.M. (2022) ‘Shoulder Injury Related to Vaccine Administration: Diagnosis and Management’, Journal of Hand Surgery Global Online, 4(2), pp. 111–117. doi:10.1016/j.jhsg.2021.12.009.

Author Images
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Ruth Werner's logo, blue R and W interlinked.
Author Bio

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP’s partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at And more information about her is available at   


Anatomy Trains is a global leader in online anatomy educationand alsoprovides in-classroom certification programs forstructuralintegration in the US, Canada, Australia,Europe, Japan, and China, as well as fresh-tissue cadaverdissectionlabs and weekend courses. The work of Anatomy Trains originated with founder Tom Myers, who mapped the human body into 13 myofascial meridians in his original book, currently in itsfourthedition and translated into 12 languages. The principles of Anatomy Trains are used by osteopaths, physical therapists, bodyworkers, massage therapists, personal trainers, yoga, Pilates,Gyrotonics, and other body-minded manual therapists and movement professionals. Anatomy Trains inspires these practitioners to work with holisticanatomy in treating system-wide patterns to provide improved client outcomes in terms of structure and function.



Full Transcript

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0:01:34.3 S1: Hi and welcome to I have a client who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I am Ruth Werner, author of a massage therapist Guide to pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned. That is harder than it looks.

0:02:20.1 S1: Today's episode comes from a massage therapist who has given me another chance to learn about something I've never heard of. It's amazing how often this podcast does that. It's a rare situation, but some doctors suggest that it may be under-reported and the treatment protocols, either through conventional medicine or massage therapy are completely unclear, and it's something we may be seeing more of soon. And it all goes like this. They wrote to me, my 75-year-old client developed shoulder pain bilaterally most recently after their second COVID booster. They believe they have Sirva, S-I-R-V-A, which stands for shoulder injury related to vaccine administration. After receiving over nine months, four COVID shots, two shingle shots and a flu vaccine, massage and gentle movement aggravate the symptoms and pain in their situation, and they also need to be prompt differently when prone. I thought I would send this question to you as there may be others seeing this in their offices, and it would be helpful to us as professionals to know what it is and what to look out for. Thanks so much. Wow, Sirva, I have never heard of this. And over the past couple of years, I have been a noisy and public supporter of vaccines when they are called for, and consequently, I have also been a frequent recipient of lots of anti-vaccine propaganda and misinformation and disinformation.

0:03:52.1 S1: And for the record, know MRNA vaccine recipients do not shed viral spike proteins that cause miscarriages in others, that was a question that came up in a webinar just last week, but here is a recognized vaccine-related injury that no one has ever asked me about. Sirva, shoulder injury related to vaccine administration. This is a real thing, although it is not well understood, here's what I was able to find out, and just so you know, I chose to share information here that I found on medical websites, not the, "Hire me to be your personal injury attorney websites." But there are lots of those. Sirva, describes acute shoulder pain after an injected vaccine. It usually appears immediately, but it may develop any time within four days after an injection. And it persists for a really long time, much longer than the two or three days of soreness many of us experience. And it does not respond to typical over-the-counter pain relievers.

0:05:00.5 S1: Sirva, was first described and defined in just 2010, when a group of 13 patients petitioned to the vaccine compensation program for help with their post-vaccine, long-term shoulder pain and limitations. It was officially added to the national vaccine injury compensation program, vaccine injury table in 2017, and since then, reports have been increasing, which explains why there are so many personal injury attorneys promoting their work in this context. Most of the reports have come from female patients, ranging in age from 19 to 89 years old. So age does not seem to be a major factor, except that we don't seem to see this in young children, maybe because they are often vaccinated in areas other than the shoulder. This complication is not at all common, thank goodness.

0:05:53.9 S1: One estimate suggests with flu vaccines that it might happen one to two times per every million doses. We don't have data on Sirva related to COVID vaccines, but we can probably expect to see more reports of this since a large portion of our population had at least one, sometimes two, three or four or more vaccines in the last year than we usually get. The theory about why it happens, appears to be that sometimes a vaccine administrator accidentally injures some tissue with the needle, a tendon or a ligament, or even the subacromial bursa or the axillary nerve. In other words, the injection doesn't just go into the thickest part of the deltoid where it's opposed to and consequently, we see a big inflammatory response either to tissue injury or to some ingredient in the vaccine, and that inflammatory response persists in very rare cases. The vaccine may also introduce pathogens into the body leading to a localized infection.

0:06:58.7 S1: Signs and symptoms of Sirva include severe shoulder pain, decreased range of motion, general shoulder weakness, and paresthesia or tingling, and all of this can persist for six months or more. The diagnostic criteria includes that the affected shoulder had no pain before the injection, that pain started within four days after the injection.

0:07:23.6 S1: That symptoms are only in the shoulder that was injected, and that tests that might include MRI and ultrasound can rule out other issues like arthritis or bone spurs or frozen shoulder. Well, this makes me wonder a few things like what if the person has signs of arthritis but had no pain before their shot, what if they already had a weakened rotator cuff tendon, but they got much worse after their shot, what about our client in this story who appears to have it bilaterally, what distinguishes this from frozen shoulder? Well, we'll come back and wrestle with those questions in a bit, but first, let's take a deeper look at what the experts say about Sirva. If a person develops this condition, they are likely to be prescribed physical therapy, maybe steroid shots to reduce inflammation and anti-inflammatory drugs, but these interventions don't have a great track record. According to Medscape, most people with Sirva have pain and limited range of motion for at least six months, maybe a third of them eventually regain full function, but the rest may have permanent limitations. A review article, and that is to say it's a research paper that collected and compared findings from other research papers.

0:08:44.5 S1: This published just in January of 2022, says this, most Sirva events have been associated with poor needle placement and/or a local reaction to the delivered serum during vaccine administration. Shoulder injury related to vaccine administration events can lead to persistent and possible permanent injury. And this review then concludes published outcomes very widely, and our understanding of Sirva remains limited. Large-scale studies are necessary to better understand the pathophysiology of Sirva, it's treatments and its outcomes. Overall, the initial priority in managing Sirva should be awareness and prevention. In other words, we don't see consistent results, we don't really know what's going on, and we won't know that until we can study it in larger populations, and in the meantime, let's be aware that this is a possible risk and let's try really hard not to injure people. Well, that sounds like good advice. But it turns out that maybe not all post-vaccine shoulder pain is Sirva.

0:09:53.1 S1: The act of getting vaccines, especially a lot of them might lead to other more typical versions of shoulder injuries exacerbating a pre-existing but low-grade rotator cuff tear, for instance, or causing enough irritation and inflammation to bother the local bursa or put pressure on some portion of the brachial plexus. Such a thing might even initiate an inflammatory spiral toward frozen shoulder, and that's a can of worms I would love to open some day, so please send me a frozen shoulder story. I think we're ready to take another look at the description of the client from today's contributor.

0:10:34.1 S1: They said, my 75-year-old client developed shoulder pain bilaterally most recently after their second COVID booster. They believe they have Sirva, shoulder injury related to vaccine administration after receiving over nine months four COVID shots, two shingle shots and a flu vaccine. Massage and gentle movement aggravate the symptoms and pain in their situation, they also need to be propped differently when prone. So based on what we know, this doesn't quite sound like Sirva, which is defined as pain following one specific vaccine and only in the affected shoulder, this lady had several vaccines, she has pain bilaterally and she's 75 and that bit of information made this quote from e-medicine stand out for me. The quote is, we found increased incidents of shoulder conditions after vaccination based on age and female sex, as well as after multiple simultaneous vaccinations among elderly persons who generally have lower muscle mass and maybe more prone to needle over-penetration. Wow, that sounds like our client. Is it really Sirva? Well no, not according to the strictest definition. Is it post-vaccine shoulder damage? It sure sounds like it could be. Does this difference matter to us? Well, it matters a little bit.

0:12:02.3 S1: Mainly it matters because it is in our client's best interest to get a clear picture of what's going on. We know this client believes she has Sirva, but we don't know if she's had an official diagnosis, for instance. And it may be that her medical team can only rule out other shoulder problems, but that is an important step in her process. Beyond that, it sounds to me like our contributors are on the right track. Careful positioning with lots of postures will help this client feel super comfortable on the table, and I bet that's something she doesn't get to feel very often. If typical massage and movements are irritating to her, we may need to go with something different, maybe warm packs or even just still holds with guided breathing. It's useful to know if she's using any inflammatories or pain killers since that may also demand more conservative treatment.

0:12:53.3 S1: In the meantime, what else can we do for her well-being, massage for her head and neck, her back, her feet, her knees. That's my favorite, when I'm feeling stressed could all be a treasured part of this person's self-care. This is the first time I have ever heard of Sirva after more than a year of a big public health push for two-dose vaccines plus boosters, especially among our mature population. Clearly, it's not something that happens very often, but I'm so glad this massage therapist brought it to my attention because maybe you have clients who are going through something similar, and if you do, and if you found some approach or technique that seems to be helpful, I would surely love to know about it.

0:13:38.2 S1: Hey everybody, thanks for listening to, I have a client who pathology conversations with Ruth Werner. Remember, you can send me your, I have a client who stories to That's ihaveaclientwho, all one word, all lowercase, I can't wait to see what you send me and I'll see you next time.