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Incorrect injection technique can result in serious shoulder injuries

Injection Technique

In early March, several news stories covered potential shoulder injuries after vaccine administration. Patients describing serious shoulder injuries were showcased on television, with some stating they “couldn’t raise their left arm” after receiving vaccinations from various types of health care providers, and others commenting that they “needed surgery to fix the damage to their shoulder.” The condition, known as Shoulder Injury Related to Vaccine Administration (SIRVA), is rare but can occur with incorrect injection technique.

SIRVA proposed mechanism 

SIRVA is thought to occur as a result of unintentional injection of a vaccine antigen into tissues and structures underlying the deltoid muscle or trauma from the needle into and around the underlying bursa. After a vaccine injection, some patients may experience severe, persistent shoulder pain and prolonged restriction of function, which are thought to occur as a result of an inflammatory reaction. 

Most patients develop symptoms within 24 to 48 hours of vaccination. When presenting to their provider, patients may be diagnosed with deltoid bursitis or other conditions, such as tendonitis, rotator cuff tear, frozen shoulder, impingement syndrome, adhesive capsulitis, and shoulder bursitis.

Literature review 

Several published case reports and case series describe patients who have had shoulder injuries after vaccinations. Atanasoff et al. published a case series in Vaccine reporting the experience of the Vaccine Injury Compensation Program with regard to shoulder injuries following vaccination.1 

A total of 13 patients were included in the series; most had received the influenza vaccine (62%), and about one-half reported that the vaccine was injected “too high” into the deltoid muscle. Results from magnetic resonance imaging revealed fluid collections in the deep deltoid, bursitis, or rotator cuff tears. About one-third of the patients required surgery, and approximately 70% had continuing symptoms, including persistent pain, limited range of motion, and pain on range of motion at the last follow-up. 

Proper injection technique 

An article published in the January/February 2013 JAPhA described proper injection technique to prevent shoulder injuries. The authors wrote that injections should be given in the thickest, most central portion of the deltoid muscle at a 90-degree angle to the skin. Other tips are to avoid vaccine injections in the upper third of the deltoid muscle and to have both the injector and the patient be seated to reduce the probability of injecting too high into the deltoid muscle. All immunization providers should be familiar with the anatomy of the shoulder to avoid giving injections too high. (See sidebar.)


  1. Vaccine. 2010;28:8049–52

Tips to avoid shoulder injuries from intramuscular injections: Technique and process 

  • Wash and dry hands thoroughly; follow community standards on wearing gloves.
  • Verify the correct vaccine, and examine the vaccine solution to ensure it is suitable for administration.
  • Choose an appropriate needle size. Use a 1-inch needle for most adult patients. For male patients weighing more than 118 kg or female patients weighing more than 90 kg, use a 1.5-inch needle; for adults weighing less than 60 kg, use a 0.625-inch needle.
  • Locate the thickest, central portion of the deltoid muscle, and wipe the desired injection site with an alcohol swab.
  • Control the limb with the nondominant hand; rest your palm against the patient’s arm so that if the patient moves, the syringe moves; and with the dominant hand, hold the syringe like a dart with your index finger and thumb.
  • Using a dart-like motion, insert the needle at a 90-degree angle with a quick thrust into the patient’s skin; push the plunger in quickly; remove the needle at the same angle as it was inserted and/or activate the safety needle protection; and discard the syringe into a biohazard container.
  • Apply slight pressure to the injection site with a cotton ball to discourage bleeding; apply an adhesive bandage.
  • Wash hands, document vaccine administration, and provide patient education and documentation of the vaccination as the patient waits in the area postvaccination to be observed for any possible reactions.
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