In the United States Court of Federal Claims
                                OFFICE OF SPECIAL MASTERS
                                         No. 15-1462V
                                    Filed: February 15, 2017
                                       Not for Publication


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BETSY REDFERN,                               *
                                             *
               Petitioner,                   *
                                             *           Hepatitis A & B vaccines (“Twinrix”);
 v.                                          *           left shoulder pain; osteoarthritis;
                                             *           no expert; motion for decision
SECRETARY OF HEALTH                          *           dismissing petition granted
AND HUMAN SERVICES,                          *
                                             *
               Respondent.                   *
                                             *
*************************************
Maximillian J. Muller, Dresher, PA, for petitioner.
Lisa A. Watts, Washington, DC, for respondent.

MILLMAN, Special Master

                                              DECISION 1

        On December 3, 2015, petitioner (now 71 years old) filed a petition under the National
Childhood Vaccine Injury Act, 42 U.S.C. § 300aa-10-34 (2012), alleging that immediately upon
receiving her first Twinrix (hepatitis A and B) vaccination in her left arm on June 30, 2014, she
had left shoulder pain. Pet. at ¶ 4. Petitioner alleges she had shoulder injury related to vaccine
administration (“SIRVA”). Instead, petitioner has osteoarthritis which her orthopedist Dr.
Williams diagnosed. Osteoarthritis 2 is a degenerative disease usually of the elderly.

1
  Because this unpublished decision contains a reasoned explanation for the special master’s action in this
case, the special master intends to post this unpublished decision on the United States Court of Federal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). Vaccine Rule 18(b) states that
all decisions of the special masters will be made available to the public unless they contain trade secrets
or commercial or financial information that is privileged and confidential, or medical or similar
information whose disclosure would constitute a clearly unwarranted invasion of privacy. When such a
decision is filed, petitioner has 14 days to identify and move to redact such information prior to the
document’s enclosure. If the special master, upon review, agrees that the identified material fits within
the banned categories listed above, the special master shall redact such material from public access.
2
  Osteoarthritis is “a noninflammatory degenerative joint disease seen mainly in older persons,
characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes
Vaccinations do not cause it.

        The Federal Circuit in Capizzano v. Secretary of Health and Human Services emphasized
that the special masters are to evaluate seriously the opinions of petitioner’s treating doctors
since “treating physicians are likely to be in the best position to determine whether a logical
sequence of cause and effect show[s] that the vaccination was the reason for the injury.” 440
F.3d 1317, 1326 (Fed. Cir. 2006); see also Broekelschen v. Sec’y of HHS, 618 F.3d 1339, 1347
(Fed. Cir. 2010); Andreu v. Sec’y of HHS, 569 F.3d 1367, 1375 (Fed. Cir. 2009). No doctors in
this case attribute petitioner’s osteoarthritis in her left shoulder to her Twinrix vaccination.

        On July 21, 2016, the undersigned issued an Order to Show Cause why this case should
not be dismissed. Afterward, petitioner filed additional records. On October 18, 2016,
petitioner requested time to develop the record. On November 2, 2016, the undersigned held a
telephonic status conference and ordered petitioner to file an expert report by January 3, 2017.
Petitioner instead decided to move to dismiss.

        On February 15, 2017, petitioner filed a Motion for a Decision Dismissing Her Petition.
Petitioner states in her motion that she “will be unable to prove that she is entitled to
compensation in the Vaccine Program.” Mot. at ¶ 2. She also states that “to proceed further
would be unreasonable and would waste the resources of the Court, the respondent, and the
Vaccine Program.” Id. at ¶ 3.

        The undersigned GRANTS petitioner’s motion and DISMISSES this case.

                                           Medical Records

                                             Prevaccination

        On April 30, 2012, petitioner went to Boulder Creek Family Medicine where she saw PA
Sue A. Griffith. Med. recs. Ex. 8, at 22. Among her concerns was arthritis in her hands,
particularly in the distal interphalangeal joint of the fifth finger of her left hand. Id. at 22, 23.

        On May 22, 2012, petitioner had a bone mineral density study. Id. at 27. Petitioner
weighed 106 pounds with a height of five foot, nine and one-half inches, which was a risk factor
for osteoporosis. Id. She had lost one and one-half inches in height. Id.

        On June 11, 2012, petitioner went to North Boulder Physical Therapy for an initial
evaluation. Med. recs. Ex. 2, at 20. Three weeks earlier, she fell and struck her left kneecap.
She reported that she had had numerous falls over the prior two years and was checked for
multiple sclerosis, which she did not have. Id. She was concerned regarding her strength and
lack of balance. Id.

in the synovial membrane. It is accompanied by pain, usually after prolonged activity, and stiffness,
particularly in the morning or with inactivity.” Dorland’s Illustrated Medical Dictionary 1344 (32nd ed.
2012) (hereinafter, “Dorland’s).
                                                    2
                                             Postvaccination

        On June 30, 2014, petitioner received her first Twinrix vaccination in her left arm. Med.
recs. Ex. 1, at 4.

       On July 28, 2014, petitioner received her second Twinrix vaccination, also in her left
arm. Id.

        Two and one-half months after receiving her first Twinrix, petitioner saw her personal
care physician, Dr. Leto Quarles, at Table Mesa Family Medicine, for her annual medical
examination on September 16, 2014. Med. recs. Ex. 8, at 59. Petitioner had a history of
bronchiectasis, 3 kidney stones, migraines, being underweight, osteopenia, and chronic lower
respiratory insufficiency. Id. She was then about eight months into long-term antibiotic therapy
for mycobacterium avium-intracellulare 4 (“MAI”) under treatment at National Jewish Health,
and had an appointment the following week for another CT scan and to reassess if she had a
component of gastroesophageal reflux disease (“GERD”) and chronic micro-aspiration as well as
the lung infection. Id. Dr. Quarles wrote, “In terms of the side effects of the long-term antibiotic
use, she remains on twice-daily probiotics and is tolerating them from a GI standpoint. She does
get occasional brief twinges of intense and very localized but migratory pain near joints with
certain movements, most frequently above the left elbow, which have been attributed to probably
low-grade tendinopathy 5 on the antibiotics, and she is tolerating this okay.” Id. On physical
examination of petitioner’s left upper extremity, she had no tenderness to palpation. Id. at 63.
Petitioner had normal shoulder, elbow, and wrist joint stability. Id. She had normal range of
motion. Id. There was no joint crepitus present and no pain with motion. Id.

        On September 19, 2014, three days after her annual examination with Dr. Quarles,
petitioner saw Dr. William J. Williams, an orthopedist. Med. recs. Ex. 2, at 8. Her chief
complaint was left upper arm/shoulder pain for about four months with decreased motion, but no
specific injury. 6 Id. Petitioner told Dr. Williams that she had episodes of acute pain in her left

3
  Bronchiectasis is “chronic dilatation of the bronchi marked by fetid breath and paroxysmal coughing,
with the expectoration of mucopurulent matter.” Dorland’s at 252.
4
  Mycobacterium avian-intracellulare complex is “a complex of Mycobacterium avium and M.
intracellulare that causes tuberculosis in birds and swine and is associated with human pulmonary disease
. . . .” Dorland’s at 397.
5
  Tendinopathy is “any pathological condition of a tendon . . . .” Dorland’s at 1881. A tendon is “a
fibrous cord of connective tissue by which a muscle is attached . . . .” Id. For a discussion of
tendinopathy associated with antimicrobial use, see Y. Khaliq and G.G. Zhanel, Fluoroquinolone-
Associated Tendinopathy: A Critical Review of the Literature, 36 Clin Infect Dis 1404-10 (2003).
http://cid.oxfordjournals.org.
6
  Curiously, on September 19, 2014, petitioner told Dr. Williams that she did not have a specific injury to
her left upper arm/shoulder, yet in her affidavit, she says when she spoke to Dr. Williams on September
19, 2014, she knew the vaccine had caused her pain. Ex. 9, ¶ 8, at 2. Also curious is that when petitioner
saw Dr. Seng on November 12, 2014 for a second opinion about her left shoulder, she told him she could
not remember a specific incident related to her shoulder pain but said the pain had an insidious onset three
months earlier, or mid-August 2014. Med. recs. Ex. 4, at 21. Furthermore, she told ALTA Physical
                                                     3
biceps muscle. 7 Pain in petitioner’s left biceps often occurred when she extended the arm and
externally rotated it and when she moved her arm behind her back. Id. Petitioner also had some
pain in her left cervical (neck) region. Id. She had a history of some chronic neck pain she
thought was related to her doing a lot of travel for her job as an engineer. Id. Petitioner said she
lifted luggage regularly and picked up her 40-pound five-year-old grandson. Id.

        On physical examination, petitioner did not have any apparent asymmetry between her
left versus right biceps or deltoid muscle. 8 Id. Petitioner did not have any tenderness over her
biceps or proximal humerus. Id. Her left shoulder was tender at the posterior and anterior
glenohumeral joint. Her acromioclavicular (“AC”) joint was non-tender. She had slight anterior
subacromial tenderness. Petitioner could actively elevate her left arm to 150 degrees and go to
170 degrees with a stretch. Full external rotation was uncomfortable at 60 degrees. Internal
rotation was more painful and mildly limited. Getting her wrist to her lower lumbar region
caused a fair amount of pain and a negative posterior liftoff test. Petitioner had satisfactory
rotator cuff strength on resisted internal and external rotation with the arm at 90 degrees of
abduction. Petitioner’s impingement tests were mildly positive. Her grip strength in her left
upper arm was intact. An x-ray of petitioner’s shoulder showed moderate glenohumeral
osteoarthritis with subchondral sclerosis and irregularity of the glenoid with a 1 mm. rimming
osteophyte. 9 Id. She had an early osteophyte at the inferior head-neck junction. Id. Petitioner
had only one or two millimeters of joint space narrowing on the axillary view. Id. Dr. Williams
diagnosed petitioner with moderate glenohumeral osteoarthritis with referred left upper arm and
shoulder pain. Id. He also diagnosed her with rotator cuff syndrome and neck pain. Id. at 9.
Dr. Williams suggested to petitioner that he administer a glenohumeral cortisone injection to
relieve petitioner’s symptoms, but petitioner did not think her pain was bad enough to have the
injection. Id. Instead, she accepted a prescription for physical therapy, and the recommendation
of taking Aleve and icing when needed. Dr. Williams suggested petitioner avoid overhead lifting
and strengthening as that would likely aggravate her glenohumeral osteoarthritis. Id.

        On October 21, 2014, petitioner had a bone mineral densitometry or DEXA performed.
Id. at 17. She had lost two inches in height. Her results showed she had osteoporosis. Id.

        On November 5, 2014, Dr. Christophe A. Nusser did an MRI of petitioner’s left shoulder


Therapy on November 13, 2014 that the onset of her left shoulder pain was about two months earlier, or
September 2014. Med. recs. Ex. 5, at 1. Clearly, petitioner never experienced pain immediately after her
June 30, 2014 or she would not have told three different providers that she did not have a specific injury
to her left upper arm/shoulder, that her problems with her left arm/shoulder had an insidious onset, and
that the onset may have been in August or September 2014.
7
  Twinrix is administered in the deltoid muscle, not in the biceps muscle. Twinrix package insert at 2;
https://www.gsksource.com/pharma (pdf) (revised May 2016).
8
  Usually, when an arm or shoulder is painful, a person will not use it as much, causing the biceps or
deltoid muscle to atrophy. Since petitioner’s left and right biceps and left and right deltoid muscles were
symmetrical on September 19, 2014 when Dr. Williams examined her, it follows that she had been using
her left arm normally since June 30, 2014, the date of her first Twinrix vaccination.
9
  An osteophyte is “a bony excrescence or osseous outgrowth.” Dorland’s at 1348.
                                                     4
without contrast to evaluate her for labral or rotator cuff tear. Id. at 15. Dr. Nusser found
minimal degenerative change in petitioner’s acromioclavicular joint. There was a mild
subacromial-deltoid fluid collection. Petitioner had mild abnormal signal intensity in her distal
supraspinatus tendon with mild bursal surface fraying and attenuation in the distal of 1 cm. She
had mild edema at the musculotendinous junction of the infraspinatus. Petitioner had mild
abnormal signal intensity in the intraarticular portion of her long head biceps tendon and
attenuation at the biceps anchor. She had degenerative signal and raying in her superior labrum
at the biceps anchor and fraying or partial tear at the posterior superior labrum with a diminutive
appearance. There was mild cartilage signal abnormality and thinning in the posterior superior
glenoid. The inferior capsule was thickened with pericapsular edema. Id.

        On November 12, 2014, petitioner saw Dr. Khemarin R. Seng, an orthopedist,
complaining of a left frozen shoulder. Med. recs. Ex. 4, at 21. She said she had an insidious
onset three months earlier, putting onset in mid-August 2014 six weeks after her first Twinrix
vaccination. In 2013, petitioner had flown 10 million miles. Id. She said she slept in odd
positions. Id. She carried luggage awkwardly. Id. In addition, petitioner could not remember a
specific incident that could have injured her left shoulder. Id. She saw Dr. Williams and
received a posterior shoulder injection, which did not help. She underwent an MRI which
showed multiple tears. She went to Dr. Seng for a second opinion. Id. Dr. Seng gave petitioner
an anterior shoulder glenohumeral joint injection. Id. He prescribed physical therapy three times
a week for four weeks. Id.

       On November 17, 2014, petitioner went to ALTA Physical Therapy with a diagnosis of
adhesive capsulitis which had an insidious onset a couple of months ago (or September 2014).
Med. recs. Ex. 5, at 1.

         On December 15, 2014, petitioner saw Dr. Seng to discuss left shoulder surgery
scheduled for January 5, 2015. Med. recs. Ex. 4, at 18. Her pain was better, but her limited
motion was the same. Physical therapy improved her motion, but then it reverted to its limited
state. Id. On physical examination, petitioner did not have any significant pain. Id. Her MRI of
the left shoulder showed mild tendinopathy and mild arthritis. Id. Petitioner said she wanted to
proceed with scope, cleanup, and capsular release with manipulation. Id.

        On January 20, 2015, petitioner saw Dr. Seng. Id. at 16. Petitioner said her left shoulder
felt okay, the pain was minimal, but her shoulder motion had not improved. Id. She wanted to
postpone surgery until summer to see if her motion improved. Id.

        On February 17, 2015, petitioner saw Dr. Seng. Id. at 13. She said her left shoulder pain
was better but her shoulder motion had not improved. Id. Petitioner said she was tired of her
current shoulder motion and had exhausted conservative measures. Id.

      On March 9, 2015, petitioner had surgery on her left shoulder for adhesive capsulitis,
impingement, rotator cuff tear, and synovitis. Id. at 28. As part of the surgery, Dr. Seng
removed a large distal clavicle osteophyte inferiorly hanging. Id. at 29.

                                                 5
        On March 16, 2015, petitioner saw Dr. Seng for a post-op visit. Id. at 11. Dr. Seng said
petitioner’s shoulder looked great. Id. She had minimal pain but more pain with internal
rotation. Id.

        On April 14, 2015, petitioner saw Dr. Seng for a re-check of her left shoulder. Id. at 9.
Her left shoulder was better than before, but petitioner had not kept up with stretching. Id. Dr.
Seng requested she refocus on motion and showed her some physical exercise. Id.

                                           DISCUSSION

       To satisfy her burden of proving causation in fact, petitioner must prove by preponderant
evidence: “(1) a medical theory causally connecting the vaccination and the injury; (2) a logical
sequence of cause and effect showing that the vaccination was the reason for the injury; and (3) a
showing of a proximate temporal relationship between vaccination and injury.” Althen v. Sec’y
of HHS, 418 F.3d 1274, 1278 (Fed. Cir. 2005). In Althen, the Federal Circuit quoted its opinion
in Grant v. Secretary of Health and Human Services, 956 F.2d 1144, 1148 (Fed. Cir. 1992):

               A persuasive medical theory is demonstrated by “proof of a logical
               sequence of cause of and effect showing that the vaccination was
               the reason for the injury [,]” the logical sequence being supported
               by a “reputable medical or scientific explanation[,]” i.e., “evidence
               in the form of scientific studies or expert medical testimony[.]”

418 F.3d at 1278.

       Without more, “evidence showing an absence of other causes does not meet petitioner’s
affirmative duty to show actual or legal causation.” Grant, 956 F.2d at 1149. Mere temporal
association is not sufficient to prove causation in fact. Id. at 1148.

       Petitioner must show not only that but for her Twinrix vaccination, she would not have
osteoarthritis in her left shoulder, but also that her Twinrix vaccination was a substantial factor in
causing her to develop osteoarthritis in her left shoulder. Shyface v. Sec’y of HHS, 165 F.3d
1344, 1352 (Fed. Cir. 1999).

       There is no evidence in these medical records that petitioner reacted to the Twinrix
vaccination she received on June 30, 2015. The Vaccine Act, § 300aa-13(a)(1), prohibits the
undersigned from ruling for petitioner based solely on her allegations unsubstantiated by medical
records or medical opinion. None of petitioner’s medical records supports her allegations.
Instead, they attribute her left shoulder problem to osteoarthritis. Petitioner has not filed a
medical expert report in support of her allegations.

      On February 15, 2017, petitioner filed a Motion for a Decision Dismissing the Petition.
The undersigned GRANTS petitioner’s Motion for a Decision Dismissing the Petition and

                                                  6
DISMISSES this case.

                                           CONCLUSION

     This petition is DISMISSED. In the absence of a motion for review filed pursuant to
RCFC Appendix B, the clerk of the court is directed to enter judgment herewith. 10


IT IS SO ORDERED.


Dated: February 15, 2017                                             /s/ Laura D. Millman
                                                                       Laura D. Millman
                                                                         Special Master




10
  Pursuant to Vaccine Rule 11(a), entry of judgment can be expedited by each party, either separately or
jointly filing a notice renouncing the right to seek review.
                                                    7
