Proper vaccination technique is key to avoiding shoulder injury

Tips for injecting the right site at the right angle

As influenza immunization season gets underway, a little brush-up on vaccination technique couldn’t hurt—especially because the National Vaccine Injury Compensation Program added shoulder injury related to vaccination administration (SIRVA) to its Vaccination Injury Table earlier this year. The table defines SIRVA as shoulder pain and limited range of motion after vaccination administration, caused by injury to the musculoskeletal structures of the shoulder such as tendons, ligaments, and bursae.

“Most people have some pain following a vaccination, and it usually goes away on its own. SIRVA is pain, weakness, and loss of function that goes on a lot longer than we expect. It can result in prolonged, even chronic pain, decreased function, and disability, and may require treatment and physical therapy,” said Tom T. Shimabukuro, MD, MBA, MPH, deputy director of CDC’s Immunization Safety Office in Atlanta.

“SIRVA occurs when vaccination is given too high on the shoulder or angled incorrectly, which puts the injection too close to the bursa and rotator cuff. If it’s too closes to the joint it can cause inflammation in the [joint’s] structures,” Shimabukuro added.

The right site

Administering intramuscular vaccines in the right spot will go a long way toward avoiding SIRVA, said Raymond Strikas, MD, MPH, FACP, medical officer in CDC’s Immunization Services Division.

“Find the bony part of the shoulder, called the acromion process, march down about two inches to the center of the deltoid, and give the injection at a 90-degree angle to the skin.”

Pharmacists should have a seat when administering intramuscular vaccines, said Stephan L. Foster, PharmD, FAPhA, APhA liaison to the CDC Advisory Committee on Immunization Practice. “Don’t stand over the patient. Make sure you’re at the same level or the needle can go in at the wrong angle.”

If there is an issue

Although proper technique won’t cause SIRVA, it’s no guarantee against other issues, said Foster. “Even though you administer the injection correctly, the patient can have an inflammatory reaction to the vaccine that cause problems with the shoulder. Ensure the vaccination is in the right location so you’ll know you didn’t cause the problem.”

There may be cases when a patient comes back to the pharmacy several days later with a complaint of shoulder pain. Pharmacists shouldn’t attempt to address the issue themselves, said Strikas. “Refer the patient back to their primary care physician or an orthopedist. They should see a provider who can make an assessment and see if it’s related to the injection, because there are a variety of places that could be injured.”

Strikas added that CDC does not currently recommend revaccination for patients who have SIRVA. “We don’t know if vaccine that ends up in the bursa, rotator cuff, or tendon is more or less effective. It hasn’t been evaluated, but we don’t recommend revaccination. We don’t have enough information to say that.”

Immunization providers should report SIRVA to the Vaccine Adverse Event Reporting System, said Shimabukuro. “It’s one thing pharmacists can do to help us monitor the safety of vaccines and monitor for possible shoulder injuries.”

How-to resources for immunization providers:

 APhA offers free online vaccination instruction videos that demonstrate proper technique.

CDC has created a new online vaccination resources library that has links to videos, job tools, reference materials, and web-based training courses.

For the full article, please visit for the October 2017 issue of Pharmacy Today.