         In the United States Court of Federal Claims
                                 OFFICE OF SPECIAL MASTERS
                                          No. 17-830V
                                    Filed: January 31, 2019
                                        UNPUBLISHED


    DEANNA WILLIAMS,
                                                             Special Processing Unit (SPU); Fact
                        Petitioner,                          Ruling; Ruling on Entitlement; Table
    v.                                                       Injury; Influenza (Flu) Vaccine;
                                                             Shoulder Injury Related to Vaccine
    SECRETARY OF HEALTH AND                                  Administration (SIRVA)
    HUMAN SERVICES,

                       Respondent.


Shealene Priscilla Wasserman, Muller Brazil, LLP, Dresher, PA, for petitioner.
Ryan Daniel Pyles, U.S. Department of Justice, Washington, DC, for respondent.

                    FINDING OF FACT AND RULING ON ENTITLEMENT1
Dorsey, Chief Special Master:
       On June 20, 2017, petitioner filed a petition for compensation under the National
Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.,2 (the “Vaccine
Act”). Petitioner alleges that she suffered a shoulder injury related to vaccine
administration (“SIRVA”) as a result of her October 22, 2014 Influenza (“flu”)
vaccination. Petition at 1-2. The case was assigned to the Special Processing Unit of
the Office of Special Masters. For the reasons described below, the undersigned finds
that petitioner is entitled to compensation.


1 The undersigned intends to post this decision on the United States Court of Federal Claims' website.
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, the
undersigned agrees that the identified material fits within this definition, the undersigned will redact such
material from public access. Because this unpublished decision contains a reasoned explanation for the
action in this case, undersigned is required to post it on the United States Court of Federal Claims'
website in accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal
Management and Promotion of Electronic Government Services).
2National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for
ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).
   I.     Procedural History

        In the petition filed on June 20, 2017, Ms. Williams asserted that she sustained a
left shoulder injury resulting from a flu vaccination on October 22, 2014. Petition at 1.
In support of her petition, Ms. Williams filed medical records (Exs. 1-3) and an affidavit
(Ex. 4). ECF No. 1. During the initial status conference held on July 24, 2017,
petitioner agreed to file any outstanding medical records and any additional records
documenting her October 22, 2014 vaccination. ECF No. 9. Petitioner also agreed to
file an affidavit addressing her delay in seeking treatment for her left shoulder pain and
explaining why she did not report her shoulder pain at a February 25, 2015 visit to her
primary care provider. Id.

       Petitioner subsequently filed additional medical records (Ex. 5) and a detailed
affidavit (Ex. 6). ECF Nos. 11-12. Petitioner confirmed that no additional vaccination
records were filed. See Informal Communication (Remark) filed October 20, 2017. In
October and November 2017, petitioner filed additional affidavits from Stefan Fujczak,
Daniel Torres, and Cindy Garcia (Exs. 7-9). ECF Nos. 15-17.

        On January 5, 2018, respondent filed a status report noting that petitioner had
not filed additional documentation regarding her vaccine administration. ECF No. 20.
Respondent requested a January 23, 2018 deadline to file a Rule 4(c) Report and
indicated that he would not entertain settlement on the current record. Id.

        Respondent filed his Rule 4(c) Report on January 19, 2018. ECF No. 21. In
respondent’s view, petitioner had provided insufficient proof of vaccine administration.
Id. at 3. Respondent further argued that, even if petitioner received a flu vaccination on
October 22, 2014, she still had not established entitlement to compensation. Id. at 4.
Specifically, respondent contended that there were “insufficient records substantiating
that the onset of petitioner’s left shoulder symptoms began within forty-eight hours of
vaccination” and a lack of documentation as to the site of vaccination. Id.
       At a status conference held on February 8, 2018, the parties indicated that they
were amenable to conducting a fact hearing to resolve the issues regarding petitioner’s
alleged October 22, 2014 flu vaccine administration and the onset of her shoulder injury.
ECF No. 24.
       On March 1, 2018, the undersigned scheduled a fact hearing for April 17, 2018,
in Washington, D.C., and stipulated that petitioner and her counsel would participate via
video conference. Id. In an e-mail dated March 1, 2018, respondent indicated that he
did not plan to call any witnesses. See Informal Communication (Remark) filed March
12, 2018. Petitioner indicated on March 21, 2018 that she would testify at the hearing



                                            2
but did not plan to call any other witnesses. ECF No. 26. Petitioner also filed an
affidavit from Winona Henebry on March 21, 2018 (Ex. 10). ECF No. 27.
       A fact hearing was held on April 17, 2018. See Minute Entry filed April 17, 2018.
In a scheduling order filed April 19, 2018, petitioner was ordered to file a complete set of
orthopedic and physical therapy records, petitioner’s pain diary, and a status report
indicating the date by which petitioner anticipated providing a letter regarding the
amount of her Medicaid lien. ECF No. 28.
        Petitioner filed her pain diary (Ex. 11) on April 23, 2018. ECF No. 29. Petitioner
filed additional physical therapy records (Ex. 12) on July 19, 2018. ECF No. 38.
Petitioner filed updated orthopedic records (Ex. 13) and an amended Statement of
Completion on August 20, 2018. ECF Nos. 40-41.
        On October 30, 2018, the undersigned filed a scheduling order noting petitioner
filed a Statement of Completion indicating that she beieved all of the relevant medical
records have been submitted. ECF No. 42. The scheduling order informed the parties
that the undersigned anticipated issuing a ruling on whether petitioner is entitled to
compensation in this case. Id. The undersigned granted the parties until November 30,
2018 to file any further evidence in regard to petitioner’s entitlement to compensation.
Id. No additional evidence was filed.
    II.     Relevant Factual History

        On October 22, 2014, petitioner presented for an appointment at her primary
care provider. Ex. 1 at 25. She was noted to have a history of diabetes,
musculoskeletal pain involving the right ankle, and snoring with associated sleep apnea,
excessive fatigue, and daytime somnolence. Id. The office visit record reflects an entry
of “Influenza, seasonal, injectable” under the “Orders” section of the record. Id. at 29.
        On November 19, 2014, petitioner returned to her primary care provider for lab
work.3   Ex. 5 at 95. The associated treatment record does not contain an entry for a
shoulder condition under the “Problem List” section, but documents entries for
petitioner’s preexisting conditions, including obesity, asthma, left knee pain, snoring,
diabetes mellitus, herpes-simplex virus 2 infection, and degenerative joint disease
involving multiple joints. Id.
       On February 25, 2015, petitioner presented for a follow-up diabetes appointment
at her primary care provider.4 Ex. 1 at 17. The “Review of Systems” section of the

3 Petitioner presented to her primary care provider again on March 11, 2015 for lab work. Ex. 5 at 107.
The associated treatment record lists the purpose of the visit as “Lab only” and does not contain sections
for petitioner’s current medical complaints, review of systems, or physical examination. Id.

4Approximately two weeks prior to this appointment, petitioner presented for a diabetic screening
appointment with an optometrist at Santa Clara Valley Medical Center Eye Clinic. Ex. 2 at 1. The
associated medical record reflects complaints of blurry vision; however, petitioner was observed to have a
normal visual examination. Id.

                                                    3
treatment record contains an entry of “Negative” for musculoskeletal complaints. Id. at
19. On examination, the physician observed that a visual overview of petitioner’s
extremities was normal. Id. at 20.
        On March 17, 2015, petitioner presented for an evaluation of possible obstructive
sleep apnea at HHS Santa Clara Valley Medical Center. Ex. 2 at 1-5. The progress
note does not reflect any complaints of shoulder symptoms. Id. On examination,
petitioner was observed to appear “well” and in no distress. Id. at 4.
       On March 19, 2015, petitioner presented for a follow-up lab and diabetes
appointment at her primary care provider. Ex. 5 at 112. The associated treatment
record does not contain an entry for a shoulder condition under the “Problem List”
section. Id. The “Review of Systems” section contains an entry of “Negative” for
musculoskeletal complaints. Id. at 114.
         On April 6, 2015, petitioner presented at her primary care provider with
complaints of musculoskeletal pain and spasms. Ex. 1 at 10. Petitioner specifically
reported that she had experienced “left shoulder pain that [had] become progressively
worse since receiving [a] flu shot at the end of October.” Id. Petitioner explained that
her pain affected her left dominant extremity and described her symptoms as worsening
with lifting. Id. On examination, petitioner was observed to have left shoulder
tenderness, pain with lifting her arm over her head, and pain with rotation of her arm.
Id. at 13. The physician assistant assessed petitioner with “left shoulder pain” and
suggested an over-the-counter NSAID for pain relief. Id. Additionally, petitioner was
referred for an MRI of her left shoulder. Id.
       A June 1, 2015 MRI of petitioner’s left shoulder revealed “moderate to severe
tendinosis of the supraspinatus, infraspinatus, and subscapularis tendons.” Ex. 5 at
135. Other findings included “small” effusion, moderate to severe osteoarthritis of the
acromioclavicular joint, and “small subacromial subdeltoid bursal fluid.” Id. The imaging
report noted “[f]eatures which may indicate predisposition to subacromial impingement.”
Id.5
         On July 17, 2015, petitioner returned to her primary care provider with complaints
of left shoulder pain that had been ongoing for nine months. Ex. 1 at 4. She stated that
she had experienced mild worsening since her last medical appointment and again
reported increased pain with lifting. Id. On examination, petitioner presented with
positive cross body testing, positive lift off testing, and abnormal strength testing. Id. at



5 In SIRVA, “symptoms are thought to occur as a result of unintended injection of vaccine antigen or
trauma from the needle into and around the underlying bursa of the shoulder resulting in an inflammatory
reaction.” 42 C.F.R. § 100.3(c)(10). “SIRVA is caused by an injury to the musculoskeletal structures of
the shoulder (e.g., tendons, ligaments, bursae, etc.).” Id. Petitioner’s June 2015 MRI findings appear to
be consistent with an injury to the bursa caused by an intramuscular injection as reported by S. Atanasoff,
et al., in Shoulder injury related to vaccine administration (SIRVA), 28 Vaccine 8049 (2010).

                                                    4
7. Petitioner’s treating physician assessed her as having a “rotator cuff injury” and
referred her for physical therapy and an orthopedic surgery consultation. Id. at 8.
        On October 6, 2015, petitioner was evaluated by an orthopedist at HHS Santa
Clara Valley Medical Center. Ex. 2 at 11. At that time, petitioner complained of left
shoulder pain that had lasted for one year and identified her pain as beginning after she
received a flu shot. Id. Petitioner reported associated difficulty with performing
overhead activity and reaching. Id. Petitioner also complained of having pain at night,
but noted that she experienced moderate symptom relief with over-the-counter NSAIDs.
Id. On examination, petitioner presented with tenderness to palpation of the left
shoulder, 170 degrees of flexion, 50 degrees of external rotation, mildly positive Neer’s
and Hawkin’s testing, and normal strength. Id. The orthopedist diagnosed petitioner
with left shoulder rotator cuff tendonitis and advised her to continue taking NSAIDs. Id.
The orthopedist also referred petitioner for physical therapy and discussed adding
injections to her course of treatment if her symptoms did not improve. Id.
        On October 27, 2015, petitioner presented for an initial evaluation at San Jose
Physical Therapy. Ex. 3 at 1. She rated her pain as ranging from “4” to “7” out of “10”
and reported that it worsened with lifting, carrying, and sleeping on her left side. Id.
She added that her pain had limited her ability to perform work as a massage therapist.
Id. Petitioner attended a total of seven physical therapy sessions from October 27,
2015 through January 8, 2016. Id. at 1-30. In a discharge summary dated January 8,
2016, petitioner was recorded as rating her pain as a “1” out of “10.” Id. at 28. She
commented that she had experienced “perceived improvement” of 75%. Id. The
physical therapist recorded improvement of petitioner’s left shoulder strength and range
of motion. Id. Petitioner was discharged to an independent home exercise program.
Id. at 30.
       On March 2, 2016, petitioner presented to her primary care provider for treatment
of a genitourinary condition. Ex. 5 at 240. The associated medical record contains an
entry of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under
the “Immunization History” section of the record. Id. at 243.
       On September 20, 2016, petitioner returned to her primary care provider for a
follow-up appointment regarding her musculoskeletal pain. Id. at 431. She again
reported that she “started having the left shoulder pain after receiving the flu vaccine in
2014.” Id. On examination, petitioner presented with tenderness of the left shoulder
with positive cross body and lift off testing. Id. at 434. Petitioner’s treating physician
assessed tendinopathy of the rotator cuff and referred her for an orthopedic surgical
consultation. Id. at 435.
       On December 8, 2016, petitioner was evaluated by an orthopedist at HHS Santa
Clara Valley Medical Center. Ex. 13 at 2-3. Petitioner reported that she had been
experiencing left shoulder pain for two years that had started after she received a flu
shot. Id. at 3. Petitioner was administered an epidural steroid injection. Id.


                                             5
       On February 28, 2017, petitioner presented to her primary care provider for
treatment of a genitourinary condition. Ex. 5 at 414. The associated record contains an
entry of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under
the “Immunizations History” section of the record. Id. at 419.
       On March 13, 2017, petitioner presented for a follow-up shoulder appointment
with her primary care provider. Id. at 443. At that time, petitioner noted that her left
shoulder symptoms had improved following an injection in December 2016; however,
she indicated that her pain had subsequently returned. Id. Petitioner added that she
believed her shoulder pain was caused by a flu shot she received in 2014. Id.
Petitioner inquired whether she could return for further orthopedic treatment. Id. The
physician assistant indicated that she would seek information regarding whether a new
referral was necessary. Id. at 445. The available record does not contain evidence of
further medical treatment related to petitioner’s alleged shoulder injury.
   III.   Affidavits Filed by Petitioner
        On June 20, 2017, petitioner filed an affidavit pursuant to § 11(c)(1). Ex. 4. In
her affidavit, petitioner asserted that she suffered a left shoulder injury caused by the flu
vaccine she received on October 22, 2014. Id. at ¶¶2-4. Petitioner averred that she
suffered the residual effects of her injury for more than six months and had not received
an award or settlement for the injury. Id. at ¶¶4-5.
        On September 29, 2017, petitioner filed a more detailed affidavit. Ex. 6. She
again averred that she was administered a flu vaccine in her left shoulder on October
22, 2014. Ex. 6 at ¶2. Following the vaccination, petitioner noted that she immediately
felt pain at the injection site. Id. at ¶3. She indicated that her pain continued over the
subsequent months, “but did not become severe until the following spring.” Id.
Petitioner averred that she informed her medical providers regarding her pain on
November 19, 2014, February 25, 2015, and March 19, 2015; however, she alleged that
these providers “did not believe [her] and dismissed [her] complaints.” Id. at ¶¶4-6.
Petitioner noted that her reports of left shoulder symptoms were first taken seriously on
April 6, 2015, at which time her medical provider ordered an MRI of her left shoulder.
Id. at ¶7.
        In October and November 2017, petitioner filed additional affidavits from Stefan
Fujczak (her friend), Daniel Torres (her friend), and Cindy Garcia (her friend). Exs. 7-9.
In his affidavit, Mr. Fujczak noted that, prior to her flu vaccination in October 2014,
petitioner had “never complained of soreness, pain, or difficulty using her left arm or
shoulder.” Ex. 7 at ¶4. Mr. Fujczak recounted an episode from October 2014 in which
he was present at petitioner’s home and was asked by petitioner to carry a case of
water up her stairs. Id. at ¶5. According to Mr. Fujczak, petitioner stated that she had
received a flu shot and had soreness in the area of the vaccination. Id. Mr. Fujczak
recalled that petitioner “would not stop complaining about her left arm being in pain
because she was left handed.” Id.


                                              6
         In his affidavit, Mr. Torres recounted an episode from a “few years ago” in which
he was present at petitioner’s house to help her prepare for a home inspection. Ex. 8 at
¶4. At that time, Mr. Torres observed that petitioner appeared to be in pain. Id.
According to Mr. Torres, petitioner told him that she was experiencing left upper
extremity pain and had previously sought medical treatment; however, petitioner
claimed that her medical provider “dismissed her complaints” and “did not believe her.”
Id. at ¶5. Mr. Torres averred that petitioner had not previously “complained of pain or
difficulty using her left arm or shoulder.” Id. at ¶7.
        In her affidavit, Ms. Garcia recounted an episode from December 12, 2014 in
which she and petitioner organized a birthday party for a mutual friend. Ex. 9 at ¶5.
Ms. Garcia recalled that petitioner asked her to carry wine and groceries from her car
due to petitioner’s shoulder pain. Id. During the party, Ms. Garcia observed that
petitioner appeared “miserable.” Id. at ¶6. According to Ms. Garcia, petitioner
explained that she was experiencing shoulder pain and eventually left early from the
gathering. Id. Ms. Garcia noted that, prior to December 2014, petitioner had never
complained of pain or difficulty using her left arm or shoulder. Id. at ¶4.
        On March 21, 2018, petitioner filed an affidavit from Winona Henebry, her friend.
Ex. 10. Ms. Henebry averred that she spoke with petitioner by phone on October 23,
2014. Id. at ¶5. Ms. Henebry explained that she remembered the specific date
because she recalled speaking to petitioner a few days prior to her October 25, 2014
birthday to make plans. Id. During the call, Ms. Henebry recounted that petitioner told
her she had been administered a flu shot and was experiencing left arm pain. Id. Ms.
Henebry averred that petitioner continued to complain of left arm pain during her
birthday dinner at Spaghetti Factory the following weekend. Id. at ¶6. Thereafter, Ms.
Henebry noted that petitioner complained “all the time” about her pain. Id. at ¶7. Ms.
Henebry recounted a specific conversation “around Thanksgiving” during which
petitioner stated that her physician did not believe her regarding her complaints of left
arm pain. Id. Ms. Henebry noted that petitioner had not complained of pain or difficulty
using her left arm or shoulder prior to October 22, 2014. Id. at ¶4.

   IV.    Testimony by Petitioner


      At the fact hearing held in Washington, D.C., on April 17, 2018, (see Transcript of
Proceedings (“Tr.”) at ECF No. 33), petitioner provided testimony regarding her alleged
October 22, 2014 vaccination, the onset of her injury, and her course of treatment.
       Petitioner explained that she was scheduled for a primary care appointment on
October 22, 2014 to obtain approval for a gastric bypass surgery. Tr. at 8. During her
appointment, petitioner testified that a nurse offered to administer a flu shot, which she
accepted. Tr. at 9. Petitioner stated that the nurse appeared to administer the vaccine
at a high location on her left upper extremity. Tr. at 9.



                                             7
        Petitioner testified that she felt a sharp, throbbing pain immediately following her
receipt of the flu vaccine. Tr. at 9-10. During the following days, she noted that the pain
grew deeper and began to radiate from the site of injection downward through her arm.
Tr. at 11. Petitioner testified that she reported her pain and other symptoms to her
mother and Winona Henebry approximately one or two days following the vaccination.
Tr. at 11-12. Thereafter, petitioner recounted that she experienced persistent pain until
February or March 2015, at which point her symptoms worsened. Tr. at 13-14.
Petitioner explained that, in addition to her preexisting symptoms, she began to
experience spasms in her left upper extremity during these months. Tr. at 13-14.
Petitioner testified that her left shoulder pain also affected her activities of daily living.
Tr. at 12. Among other things, she noted that her shoulder injury necessitated
assistance from her friends with housekeeping and carrying items up and down the
stairs. Tr. at 12.
        Petitioner testified that she reported left shoulder symptoms to her medical
providers prior to April 6, 2015—the date on which her medical records first reflect
complaints of shoulder pain. Tr. at 14-17. Specifically, petitioner indicated that she
complained of left shoulder symptoms at medical appointments on November 19, 2014,
February 25, 2015, and March 19, 2015. Tr. at 14-17. In general, petitioner testified
that her medical providers dismissed her complaints during those appointments and did
not follow up with further examinations. Tr. at 14-17. Petitioner noted that she probably
did not reference her shoulder condition other than in passing at a sleep clinic
evaluation on March 17, 2015 because her shoulder symptoms did not have any
bearing on the medical issue at hand. Tr. at 17-18.
       Petitioner testified that she did not seek urgent or emergency care following her
vaccination because she underestimated the severity of her injury. Tr. at 18. She
explained that she eventually sought specific treatment for her left shoulder on April 6,
2015 because her pain had started to worsen and she was beginning to experience
spasms. Tr. at 18. Petitioner also noted that, at prior medical appointments, she was
told that she needed to make a specific appointment for her left shoulder pain in order to
receive dedicated treatment for that condition. Tr. at 18-19.
   V.     Respondent’s Opposition
        Respondent filed a Rule 4(c) Report on January 19, 2018. See Respondent Rule
4(c) Report (“Res. Report”), filed January 19, 2018 (ECF No. 21). Initially, respondent
argues that petitioner has not established proof of vaccination. Id. at 3-4. Respondent
notes that petitioner was previously ordered to file a more detailed vaccination record
but failed to provide additional evidence. Id. As a result, respondent contends that the
“proof of vaccine administration is insufficient on the current record.” Id. at 3.
        Respondent further argues that, even if the site of vaccination could be
established, petitioner has not provided sufficient evidence to support her SIRVA claim.
Id. at 4-5. Respondent specifically contends that “in addition to a lack of documentation


                                              8
of the site of vaccination” there are insufficient records to substantiate that the onset of
petitioner’s left shoulder symptoms began within 48 hours of vaccination. Id. at 4.
Respondent notes that petitioner’s medical records reflect four medical encounters in
the months after her alleged vaccination that do not reference shoulder complaints. Id.
at 4-5. Respondent asserts that petitioner first attributed her shoulder pain to the
vaccination five-and-a-half months after the alleged vaccination. Id. at 5. Given the
aforementioned issues, respondent requests that this case be dismissed. Id.
    VI.      Findings of Fact
       Before ruling on entitlement in this case, the undersigned must make the
following factual determinations: (1) whether petitioner was administered an influenza
vaccine on October 22, 2014 in her injured left arm and (2) whether petitioner’s shoulder
symptoms began within 48 hours of her alleged vaccination.
        When making these factual findings, the undersigned adheres to the
preponderance of evidence standard as set forth in Section 13(a)(1)(A) of the Vaccine
Act. Under that standard, the existence of a fact must be shown to be “more probable
than its nonexistence.” In re Winship, 397 U.S. 358, 371 (1970) (Harlan, J., concurring).
        Pursuant to Section 13(b)(2) of the Vaccine Act, the undersigned may find that
the first symptom or manifestation of onset of an injury described in a petition occurred
within the time period described in the Vaccine Injury Table even though the occurrence
of such symptom or manifestation was not recorded if such finding is otherwise
supported by a preponderance of the evidence.
          A. Finding of Fact Regarding Receipt and Site of Flu Vaccination
        Upon review of the entire record and consideration of the parties’ contentions,
the undersigned finds that there is preponderant evidence that petitioner received a flu
vaccination on October 22, 2014 in her left shoulder. Contrary to respondent’s
argument, petitioner has filed substantial evidence that a flu vaccine was administered
in her left shoulder on that date.
       Initially, an office visit record from petitioner’s primary care provider dated
October 22, 2014 reflects an entry of “Influenza, seasonal, injectable” under the
“Orders” section of the record. Ex. 1 at 29. As indicated above, subsequent records
from petitioner’s primary care provider on March 2, 2016 and February 28, 2017 contain
entries of “Influenza, seasonal, injectable” with a “date given” of October 22, 2014 under
the “Immunization History” section of the records. Ex. 5 at 243, 419. Considered
together, the aforementioned medical records reflect substantial evidence that petitioner
received a flu vaccination on October 22, 2014.6


6The undersigned notes, however, that several prior decisions within this program have held that the fact
of vaccination need not be supported by medical records or opinion pursuant to Section 13(a) of the
Vaccine Act. See, e.g., Centmehaiey v. HHS, 32 Fed. Cl. 612, 621 (1995), aff’d 73 F.3d 381 (Fed. Cir.

                                                    9
        In addition, petitioner’s treatment records consistently attribute her left shoulder
symptoms to a flu vaccination she received in October 2014. These medical records
provide strong corroborating evidence that petitioner received a flu vaccination in her
left shoulder on October 22, 2014. See, e.g., Parker v. HHS, No. 15-1331V, 2016 WL
3443929 (Fed. Cl. Spec. Mstr. May 13, 2016) (finding that a vaccine record recording
administration in the left arm was incorrect based primarily on petitioner’s consistent
attribution of his right shoulder condition to his vaccination throughout his treatment).
Notably, at petitioner’s medical appointment on April 6, 2015 in which she first received
dedicated treatment for her left shoulder symptoms, petitioner specifically reported that
she had experienced “left shoulder pain that [had] become progressively worse since
receiving [a] flu shot at the end of October.” Ex. 1 at 10. Thereafter, petitioner
consistently attributed her left shoulder injury to a flu vaccination from the same period.
See, e.g., Exs. 2 at 11; 5 at 431, 443; 13 at 3.
       The undersigned also found petitioner to be a highly credible witness whose
testimony was corroborative of the aforementioned medical records regarding the date
and location of her flu vaccination. Moreover, petitioner filed affidavits from her
acquaintances that credibly recount statements made by petitioner in the days and
weeks after October 22, 2014 in which she linked her sudden-onset left shoulder
symptoms to an earlier flu shot. Exs. 7 at ¶¶4-5; 10 at ¶¶4-5. Based on all of the
above, the undersigned finds that there is preponderant evidence that petitioner
received a flu vaccination on October 22, 2014 in her left shoulder.
        B. Finding of Fact Regarding Onset
      Upon review of the entire record and consideration of the parties’ contentions,
the undersigned finds that there is preponderant evidence that petitioner’s alleged
shoulder symptoms occurred within 48 hours of petitioner’s October 22, 2014 flu
vaccination.
        As described above, petitioner credibly testified at the fact hearing that she felt a
sharp, throbbing pain immediately following her receipt of the flu vaccine on October 22,
2014. Tr. at 9-10. During the following days, she noted that the pain grew deeper and
began to radiate from the site of injection downward through her arm. Tr. at 11.
Petitioner’s testimony is corroborated by her post-vaccination medical records. Indeed,
at petitioner’s medical appointment on April 6, 2015, she specifically reported “left

1995) (stating that “[t]he lack of contemporaneous, documentary proof of a vaccination, however, does
not necessarily bar recovery.”); see also Wonish v. HHS, No. 90-667V, 1991 WL 83959, at *4. (Fed. Cl.
Spec. Mstr. May 6, 1991) (stating that “[v]accination is an event that in ordinary litigation could be
established by lay testimony. Medical expertise is not typically required.”); Woodson v. HHS, No. 91-
263V, 1992 WL 59707, at *2. (Fed. Cl. Spec. Mstr. Mar. 5, 1992) (finding that “the petition should not be
dismissed as a matter of law merely because there is no documentary evidence that the vaccination took
place and [petitioner] is the only witness claiming personal knowledge of the vaccination. Her testimony
on this point must be weighed in the context of the entire record.”). In any event, the undersigned has
found medical records corroborating petitioner’s allegations.


                                                   10
shoulder pain that [had] become progressively worse since receiving [a] flu shot at the
end of October.” Ex. 1 at 10. The undersigned finds this notation to be corroborating
evidence that petitioner’s shoulder pain began on October 22, 2014 and worsened in
the following months. At subsequent medical appointments, petitioner explicitly linked
her left shoulder pain as beginning after her receipt of a flu vaccination. See, e.g., Exs.
2 at 11; 5 at 431, 443; 13 at 3.
       Respondent notes that petitioner’s medical records reflect four intervening
medical encounters between October 22, 2014 and April 6, 2015 that do not reference
shoulder complaints.7 Res. Report at 4-5. However, the undersigned finds that the
relevant medical records, when reviewed in conjunction with petitioner’s testimony,
provide a plausible and credible explanation for this omission. Initially, the undersigned
notes that the medical record for petitioner’s November 19, 2014 appointment lists the
purpose of the visit as “Lab only” and does not contain sections for petitioner’s current
medical complaints, review of systems, or physical examination. Ex. 5 at 95.
Furthermore, petitioner’s medical appointments on February 25, March 17, and March
19, 2015 were for specific medical concerns unrelated to petitioner’s left shoulder
condition. Exs. 1 at 17; 2 at 1-5; 5 at 112.
       Although the aforementioned treatment records do not contain any references to
shoulder complaints, petitioner credibly testified that she did, in fact, report left shoulder
symptoms to her medical providers on November 19, 2014, February 25, 2015, and
March 19, 2015.8 Tr. at 14-17. Petitioner testified that her medical providers dismissed
her complaints during those appointments and did not follow up with further
examinations.9 Tr. at 14-17. In this case, the undersigned is persuaded that petitioner’s
detailed testimony is in harmony with the contemporaneous records and provides
additional credible statements regarding her condition that are absent or omitted from
the medical records.
        Finally, although petitioner did not seek dedicated treatment for her left shoulder
injury until April 6, 2015—approximately five-and-a-half months following her October
22, 2014 vaccination—the undersigned does not find the delay in treatment to be
dispositive regarding the issue of onset. Indeed, as described above, petitioner testified
that she did not seek urgent or emergency care following her vaccination because she
underestimated the severity of her injury. Tr. at 18. She noted that she eventually

7In the “Facts” section of Respondent’s Rule 4(c) report, respondent specifically cites petitioner’s medical
appointments on November 19, 2014 and February 25, March 17, and March 19, 2015. See Res. Report
at 2.

8During the hearing, petitioner specifically testified that she probably did not reference her shoulder
condition other than in passing at a sleep clinic evaluation on March 17, 2015 because her shoulder
symptoms did not have any bearing on the medical issue at hand. Tr. at 17-18.
9 As described above, Mr. Torres and Ms. Henebry also recounted in their affidavits that petitioner told
them that her medical provider had dismissed her initial reports of left shoulder symptoms. See Exs. 8 at
¶5; 10 at ¶7.

                                                     11
sought dedicated treatment for her left shoulder on April 6, 2015 because her pain had
started to worsen and she had begun to experience spasms. Tr. at 18. Petitioner also
explained that, at prior medical appointments, she was told that she needed to make a
specific appointment for her left shoulder pain in order to receive dedicated treatment
for that condition. Tr. at 18-19. In the undersigned’s experience, petitioner’s sworn
testimony and medical records together reflect a pattern of treatment consistent with,
and similar to, other SIRVA claims.
        In light of all of the above and in view of the record as a whole, the undersigned
finds that there is preponderant evidence that petitioner’s alleged shoulder symptoms
occurred within 48 hours of petitioner’s October 22, 2014 flu vaccination.
   VII.   Ruling on Entitlement
        In light of the above findings of fact, the undersigned further finds that this case is
ripe for adjudication on the question of petitioner’s entitlement to compensation for her
alleged SIRVA. For the reasons described below, the undersigned finds that petitioner
is entitled to compensation.
       A. Legal Standard
       Effective for petitions filed beginning on March 21, 2017, SIRVA is an injury listed
on the Vaccine Injury Table (“Table”). See Vaccine Injury Table: Qualifications and Aids
To Interpretation. 42 C.F.R. § 100.3(c)(10). A vaccine recipient shall be considered to
have suffered SIRVA if such recipient manifests all of the following:
       (i) No history of pain, inflammation or dysfunction of the affected shoulder prior to
       intramuscular vaccine administration that would explain the alleged signs,
       symptoms, examination findings, and/or diagnostic studies occurring after
       vaccine injection; (ii) Pain occurs within the specified time-frame; (iii) Pain and
       reduced range of motion are limited to the shoulder in which the intramuscular
       vaccine was administered; and (iv) No other condition or abnormality is present
       that would explain the patient's symptoms (e.g. NCS/EMG or clinical evidence of
       radiculopathy, brachial neuritis, mononeuropathies, or any other neuropathy).
Id. The time period by which the symptomatology must begin is within 48 hours of
vaccination. Id. at § 100.3(a)(XIV)(B).
       B. The Elements of Petitioner’s SIRVA Claim
       The undersigned’s findings and conclusions are as follows:
          1. Petitioner did not have a history of pain, inflammation, or
             dysfunction of the affected shoulder prior to vaccine intramuscular
             administration
       The undersigned reviewed Ms. Williams’s medical history prior to her October 22,
2014 flu vaccination. Petitioner did not have a history of pain, inflammation, or

                                              12
dysfunction of her left shoulder prior to vaccination. Thus, petitioner satisfies this
criterion.
           2. Onset occurred within the specified time frame
       As described in Section (VI)(B) above, based upon the undersigned’s review of
the entire record and consideration of the parties’ contentions, the undersigned finds
that there is preponderant evidence that petitioner’s alleged shoulder symptoms
occurred within 48 hours of her October 22, 2014 flu vaccination.
           3. Pain and reduced range of motion were limited to the shoulder in
              which the intramuscular vaccine was administered
        Petitioner reported on April 6, 2015 that she had experienced “left shoulder pain
that [had] become progressively worse since receiving [a] flu shot at the end of
October.” Ex. 1 at 10. Petitioner reported that her pain affected her left dominant
extremity and described her symptoms as worsening with lifting. Id. On examination,
petitioner was observed to have left shoulder tenderness, pain with lifting her arm over
her head, and pain with rotation of her arm. Id. at 13.
        Thereafter, as described above, petitioner reported left shoulder pain at multiple
medical appointments. See, e.g., Exs. 1 at 4; 2 at 11; 3 at 1; 5 at 431, 443; 13 at 3. On
several examinations, petitions was observed to have reduced range of motion of the
left shoulder. See, e.g., Exs. 2 at 11; 5 at 198; 13 at 3. Based upon the undersigned’s
review of the record, petitioner’s pain and reduced range of motion were limited to the
left shoulder during the period at issue.
           4. No other condition or abnormality was present that would explain the
              patient’s symptoms (e.g. NCS/EMG or clinical evidence of
              radiculopathy, brachial neuritis, mononeuropathies, or any other
              neuropathy)
      There is no evidence in the record that demonstrates any other type of condition
or abnormality was present that would explain petitioner’s symptoms.
       C. Factors Unrelated to Vaccination
      Respondent has not asserted, nor would the undersigned find, that there is any
evidence in the record to support respondent’s burden of establishing an alternative
cause for petitioner’s injury unrelated to vaccination.

   VIII.   Conclusion
        In light of all of the above and in view of the record as a whole, the undersigned
finds that (1) petitioner received an influenza vaccination in her left upper extremity on
October 22, 2014; (2) the onset of petitioner’s left shoulder symptoms occurred within
48 hours of vaccine administration; and (3) that petitioner has established the Table
requirements for a SIRVA caused by her October 22, 2014 vaccination. For the
                                             13
reasons described above, the undersigned finds that petitioner is entitled to
compensation.


IT IS SO ORDERED.


                                                 s/Nora Beth Dorsey
                                                 Nora Beth Dorsey
                                                 Chief Special Master




                                            14
