         In the United States Court of Federal Claims
                                 OFFICE OF SPECIAL MASTERS
                                          No. 17-1179V
                                      Filed: March 11, 2020

    * * * * * * * * * * * * *                  *    *
    MAUREEN C. CLAVIO,                              *      UNPUBLISHED
                                                    *
                 Petitioner,                        *
    v.                                              *      Fact Ruling on the Record; Findings of
                                                    *      Fact and Conclusions of Law; Onset
    SECRETARY OF HEALTH                             *      Ruling; Influenza (“Flu”) Vaccine;
    AND HUMAN SERVICES,                             *      Shoulder Injury Related to Vaccine
                                                    *      Administration (“SIRVA”)
                 Respondent.                        *
                                                    *
                                                    *
    * * * * * * * * * * * * *                  *    *

Leah Durant, Esq., Law Offices of Leah V. Durant, PLLC, Washington, DC, for petitioner.
Debra Begley, Esq., U.S. Department of Justice, Washington, DC, for respondent.

                        FINDING OF FACTS AND RULING ON ONSET1

Roth, Special Master:

        On August 31, 2017, Maureen Clavio (“Ms. Clavio”) filed a petition for compensation
pursuant to the National Vaccine Injury Compensation Program.2 The petition alleges that Ms.
Clavio received a tetanus (“Tdap”) vaccination on February 2, 2012, and “[o]ver the next 24-48
hours, Ms. Clavio’s arm and shoulder near the vaccine site became swollen and painful…”. See
Petition at ¶¶1, 2, ECF No. 1. The petition further alleges that her injury persisted in excess of six
months. Id. at ¶10.


1
  Although this Ruling has been formally designated “unpublished,” it will nevertheless be posted on the
Court of Federal Claims’s website, in accordance with the E-Government Act of 2002, Pub. L. No. 107-
347, 116 Stat. 2899, 2913 (codified as amended at 44 U.S.C. § 3501 note (2006)). This means the Ruling
will be available to anyone with access to the internet. However, the parties may object to the Ruling’s
inclusion of certain kinds of confidential information. Specifically, under Vaccine Rule 18(b), each party
has fourteen days within which to request redaction “of any information furnished by that party: (1) that is
a trade secret or commercial or financial in substance and is privileged or confidential; or (2) that includes
medical files or similar files, the disclosure of which would constitute a clearly unwarranted invasion of
privacy.” Vaccine Rule 18(b). Otherwise, the whole Ruling will be available to the public. Id.
2
 National 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. Background

A.      Procedural History

        The petition was filed on August 31, 2017. ECF No. 1. Petitioner originally filed her
petition pro se; Ms. Durant was substituted in as counsel on August 30, 2018. See ECF No. 25.

        This matter was assigned to me on September 5, 2017. ECF No. 4. An Order was issued
that same day encouraging petitioner to seek counsel; a list of attorneys licensed to practice in the
Vaccine Program was enclosed. ECF No. 5.

        On September 8, 2017, petitioner filed medical records from her orthopedist, chiropractor,
primary care provider, neurologist, and dentist. See Pet. Ex. 1-6, ECF No. 7. She also filed a letter
from Dr. Boll, dated May 18, 2017, in which he stated that he recalled her having complained of
shoulder pain beginning 24 to 48 hours after vaccination. Pet. Ex. 7, ECF No. 7. Dr. Boll stated
that he did not have petitioner’s medical records when he wrote the letter and could not verify the
facts or dates as to what he wrote. Id. A statement from petitioner was filed as Pet. Ex. 8. ECF No.
7.

        A recorded status conference was held on November 1, 2017. An in-depth conversation
was had with petitioner regarding the medical records that she filed in support of her petition.
Scheduling Order at 1, ECF No. 10. It was noted that, although petitioner alleges that she had pain
immediately following receipt of the Tdap vaccination, this history was not supported by her
records. Id. It was emphasized to petitioner that contemporaneous medical records are given
greater weight in the Vaccine Program. Id. at 2. The requirement for injuries to last in excess of
six months was also discussed. Id. Petitioner was encouraged to file additional medical records,
particularly any records documenting care or treatment of her left shoulder. Id.

        On November 7, 2017, petitioner filed letters from two co-workers at Carl Sandberg High
School, David Kreis, the school’s athletic trainer, and Nancy Cassidy, the school nurse. Pet. Ex.
8-9, ECF No. 11.3 On December 12, 2017, petitioner filed letters from her mother, Florine Martin,
and her husband, Wayne Clavio. Pet. Ex. 10-11, ECF No. 12. On December 29, 2017, petitioner
filed letters from a former co-worker, Yolanda Kolliniatis, and a friend, Jeannie Murawski. Pet.
Ex. 12-13, ECF No. 13.

        On January 1, 2018, the Court issued an order for respondent to file a status report
indicating how he would like to proceed in this matter. Status Report (“S.R.”) Order, ECF No. 14.

        Respondent filed a status report on April 9, 2018, stating that he would continue to defend
this case and proposing to file a Rule 4(c) Report in 45 days. Resp. S.R. at 1, ECF No. 17.
Respondent also requested that petitioner file all records from petitioner’s primary care physician
for the two years prior to petitioner’s Tdap vaccination on February 2, 2012, and all medical

3
  Both petitioner’s statement and Mr. Kreis’s statement were filed as Pet. Ex. 8. In his Rule 4(c) Report,
respondent referenced petitioner’s statement as Pet. Ex. 8 and Mr. Kreis’s statement as Pet. Ex. 8.2 to avoid
confusion. See Rule 4 Rpt. at 9, n.11. Petitioner adopted these citations for her Motion. See Motion at 5,
n.1. For continuity purposes, I will adopt these citations as well.


                                                     2
records pertaining to petitioner’s left shoulder and right arm pain between June 29, 2012 and
February 11, 2013. Id.

       An order was issued on April 11, 2018, for petitioner to file the records requested by
respondent by May 11, 2018. Scheduling Order at 2, ECF No. 18. Respondent was ordered to file
his Rule 4(c) Report by June 1, 2018. Id. On May 10, 2018, petitioner contacted my chambers via
telephone to request an extension of time to file her medical records. See Informal Communication,
dated May 10, 2018. Petitioner was ordered to file her medical records or a status report by June
1, 2018. Scheduling Order at 1, ECF No. 20. Respondent was ordered to file his Rule 4(c) Report
by July 2, 2018. Id.

       Petitioner filed additional primary care records on June 6, 2018. Pet. Ex. 14, ECF No. 21.

        Respondent filed his Rule 4(c) Report on June 28, 2018. Resp. Report, ECF No. 22.
Respondent submitted that petitioner’s alleged injury did not fit the criteria for SIRVA because
petitioner did not provide evidence that her pain began within 48 hours of vaccination and her pain
and reduced range of motion were not limited to her left shoulder. Id. at 12. Respondent pointed
out that, based on the medical records, petitioner first reported left shoulder pain on June 13, 2012,
four months post-vaccination. Id. at 3, 13. Respondent further noted that multiple medical records
indicate that petitioner reported pain in her temple and neck in addition to her left shoulder. Id. at
14. Moreover, petitioner retained full range of motion in her left shoulder. Id.

        A recorded status conference was held on July 31, 2018. During the conference, petitioner
advised that she had not hired an attorney but was receiving filing and strategy assistance from a
vaccine attorney. S.R. Order at 1, ECF No. 24. The issue of onset in this matter was once again
discussed. Id. at 1-2. Petitioner was advised that there was nothing in the medical records to support
an onset of her left shoulder pain prior to April 2012. Id. It was noted that petitioner and her doctors
consistently placed the onset of shoulder pain in April 2012, two months post-vaccination. Id. It
was further noted that petitioner did not complain of left shoulder pain when she presented to Dr.
Boll’s office on February 29, 2012, 25 days after receiving the Tdap vaccine. Id. at 2. Petitioner
was advised that contemporaneous medical records are typically given more weight than
allegations made years later. Id. Petitioner was further advised of various ways to exit the Vaccine
Program. Id.

        Leah Durant substituted in as counsel on August 30, 2018. ECF No. 25. That same day,
petitioner filed a status report advising the Court that she intended to file a Motion for a Ruling on
the Record. ECF No. 27. Petitioner requested 60 days to file her Motion. Id. An Order was issued
for petitioner to file a Motion for Ruling on the Record by November 9, 2018. Non-PDF Order,
issued Sept. 10, 2018. Petitioner requested and received two extensions of time. See Unopposed
Motion for Extension of Time, ECF No. 29; Non-PDF Order, issued Nov. 13, 2018; Unopposed
Motion for Extension of Time, ECF No. 30; Non-PDF Order, issued Dec. 3, 2018.

        On December 3, 2018, Petitioner filed a Motion for a Ruling on the Record (“Motion”) “as
to the issue of onset.” Motion at 1, ECF No. 31. Petitioner submitted that the onset of her injury
occurred within 48 hours of vaccination. She further submitted that she met the criteria for a Table
SIRVA and is entitled to vaccine compensation. Id. at 4-5.



                                                   3
       Respondent requested and received two extensions of time to file his response. Unopposed
Motion for Extension of Time, ECF No. 32; Non-PDF Order, issued Dec. 18, 2018; Unopposed
Motion for Extension of Time, ECF No. 33; Non-PDF Order, issued Feb. 27, 2019. On April 15,
2019, respondent filed a response (“Response”) to petitioner’s Motion. ECF No. 34. Respondent
submitted that petitioner has not provided preponderant evidence that her symptoms began within
48 hours of vaccination and therefore, petitioner does not qualify for an on-Table claim because
she does not meet the QAI criteria for a SIRVA claim. Response at 1, 8. More specifically,
respondent asserted that the onset of petitioner’s symptoms began “no sooner than mid-April 2012,
over two months after her Tdap vaccination,” based on petitioner’s presentation to Dr. Boll on
June 13, 2012, complaining of left shoulder pain for two months. Id. at 1.

      Petitioner filed a reply (“Reply”) on June 13, 2019 in which she responded to respondent’s
arguments regarding the onset of her alleged vaccine injury. ECF No. 38.

       This matter is now ripe for determination.

B.     Summary of Relevant Medical Records

        Petitioner’s medical history is significant for complaints related to her hips and knees. See
Pet. Ex. 2 at 5-9; Pet. Ex. 4 at 38-39, 84. She also took Crestor for high cholesterol. See Pet. Ex.
14 at 25-27.

       Petitioner received a Tdap vaccine on February 2, 2012, at the office of her primary care
physician, Dr. Boll. Pet. Ex. 1 at 1; Pet. Ex. 4 at 10; Pet. Ex. 14 at 5.

       On February 27, 2012, petitioner presented to Maya Karam, a nurse practitioner at Dr.
Boll’s office, with complaints of nasal congestion, sore throat, non-productive cough, ear pain,
and pain on the left side of her face and teeth. Pet. Ex. 4 at 13, 15; Pet. Ex. 14 at 6. She was
diagnosed with sinusitis and prescribed an antibiotic. Id. at 14; Pet. Ex. 14 at 7. There was no
mention of any shoulder pain made at that appointment.

       On May 3, 2012, petitioner faxed the results of bloodwork performed by her employer to
Dr. Boll. Pet. Ex. 4 at 72; Pet. Ex. 14 at 9. Petitioner asked Dr. Boll to call her to discuss her red
blood cell distribution levels, iron count, and carbon dioxide levels. Id.

        On May 10, 2012, petitioner presented to her dentist, Dr. Corski, for temporomandibular
joint (“TMJ”) pain. Pet. Ex. 6 at 1. She was prescribed Flexeril and Motrin. Id. Petitioner returned
to Dr. Corski on May 23, 2012, for hand scale polishing. Id. She complained of left-sided TMJ
which was very tender to the touch. Id.

        Petitioner returned to Dr. Boll’s office on June 13, 2012 with complaints of left shoulder
pain and left-sided temporal pain for two months. Pet. Ex. 4 at 9; Pet. Ex. 14 at 12. She also had a
headache that was mild to moderate with no relief from Advil or Flexeril prescribed by her dentist.
Pet. Ex. 4 at 9. She complained of difficulty raising her left arm. Id. She had no weakness and only
mild associated posterior left neck pain. Id. Upon exam, petitioner had full range of motion of the
cervical spine and full range of motion of the left shoulder with some pain posteriorly. Id. at 12;



                                                  4
Pet. Ex. 14 at 14. Dr. Boll suspected tendonitis leading to compensatory neck muscle pain. Id. He
referred her for a physical therapy evaluation. Id.

         On June 18, 2012, petitioner presented to an orthopedist, Dr. Regan, with complaints of
left temple pain down into her shoulder with “spontaneous onset.” Pet. Ex. 2 at 3. Upon exam,
petitioner had no tenderness around her shoulder, full range of motion, good circulation, good
sensation, and good motor function to her arm and hand. Id. An x-ray was “unremarkable.” Id. Dr.
Regan’s impression was “[n]ot sure this correlates well with a shoulder problem, but it is peculiar
that this radiates from her shoulder up to her temple area.” Id. She was advised to see a neurologist.
Id.

        A record signed by Dr. Regan4 bearing “6-2012” as the date of service noted a telephone
call from petitioner: “The patient called back and talked with me today and she wants it mentioned
in the chart that she may be ALLERGIC TO TETANUS-DIPHTHERIA-PERTUSSIS injection,
so we will make sure that in the future we do not give her any of those injections, but we do not
do that at this office.” Pet. Ex. 7 at 2 (emphasis in original).

        On June 29, 2012, petitioner presented to Dr. Mayer, a neurologist, complaining of head
pain that radiated down to her shoulder. Pet. Ex. 5 at 10; Pet. Ex. 4 at 32; Pet. Ex. 14 at 15. She
described pain over the left temple, left neck, and left shoulder. Pet. Ex. 5 at 10. Petitioner reported
that the pain started in her left neck or temple “around Easter time in April” and later became
associated with pain in her left shoulder. Id. Dr. Mayer noted that petitioner felt that all three areas
of pain were related. Id. Petitioner reported that the pain was present “to some degree on a daily
basis, but can be relatively mild at times.” Id. She was noted to have not lost any function, had
“recently hiked up a mountain in Colorado” and continued to golf. Id. She did not have any
associated nausea or vomiting or weakness in her arm. Id. An x-ray of her left shoulder was
unremarkable. Id. Upon exam, petitioner had a normal range of motion with pain on abduction and
external rotation of the left shoulder which radiated to her temple. Id. at 11; Pet. Ex. 4 at 33; Pet.
Ex. 14 at 16. X-rays of her cervical spine showed lordosis in the neck, possibly due to muscle
spasm and slight disc narrowing at C3-4 but no other significant findings. Pet. Ex. 5 at 12; Pet. Ex.
4 at 34; Pet. Ex. 14 at 17. Dr. Mayer’s assessment was neck strain which was mainly muscular and
involved the trapezius and temporalis muscles. Pet. Ex. 5 at 12. She was prescribed gabapentin
and instructed to follow-up in four to six weeks. Id.; Pet. Ex. 4 at 34-35; Pet. Ex. 14 at 17-18.

      Petitioner did not show up for her follow-up visit with Dr. Mayer that was scheduled for
August 7, 2012. Pet. Ex. 5 at 3-4.

        Petitioner did not show up for a dental cleaning scheduled for October 8, 2012. Pet. Ex. 6
at 1. She presented to Dr. Corski on October 27, 2012. He noted that she was very jumpy and
sensitive, making scaling difficult. Id. at 1-2. He encouraged flossing. Id.

        On October 27, 2012, petitioner presented to Dr. Boll’s office for a flu vaccine. Pet. Ex. 14
at 19. She received a flu vaccine in her left arm. Pet. Ex. 4 at 7.


4
 This record was not filed with the other records from Dr. Regan’s office (Pet. Ex. 2). Rather, this record
was filed with the letter from Dr. Boll as Pet. Ex. 7.


                                                    5
        On November 21, 2012, petitioner underwent a treadmill stress echocardiogram. Pet. Ex.
14 at 20. It was a normal treadmill exercise study; petitioner achieved her target heart rate and did
not have any arrhythmias. Id.

         There are no further records of any medical treatment or visits until February 11, 2013,
when petitioner presented to a chiropractor, Dr. Cleofe, with complaints of pain in her left arm,
neck, and temple area, and pain from her left hip to the knee. Pet. Ex. 3 at 4. She described the
pain in her shoulder, neck, and temple as aching and stiffness, while the pain in her hip and knee
was characterized as “sharp.” Id. Petitioner reported that in April 2012, she woke up with pain in
her left temple; she later noticed it in her left arm and her neck, and it was progressing to her right
upper arm as well. Id. at 11. She had not missed any work due to her symptoms and reported that
they affected her life “mildly,” but she did have difficulty donning and doffing shirts and coats. Id.
at 1, 2, 7. Her condition had become worse since October of 2012. Id. at 11. She described feeling
“achy all over,” like she was “getting old and falling apart…”. Id. at 1. Upon exam, she had pain
with left shoulder abduction. Id. at 2. Cervical spine x-rays were performed and showed
degenerative disc disease from C3 to C6. Id. at 22. The soft tissue structures were unremarkable
and there was no evidence of joint pathology. Id. When asked about possible precipitating events,
petitioner stated she had a Tdap vaccination in her left shoulder in April 2012, one day before all
the pain began. Id. at 2, 11. Dr. Cleofe questioned whether petitioner had a gradual, insidious onset
of rotator cuff disease. Id. at 1. He recommended an eight-week course of treatment involving
myofascial release therapy, shoulder rehabilitation protocols, and TMJ soft tissue therapy. Id. at 2.

        Petitioner returned for chiropractic treatment on February 15, 18, 20, 22, 25, and 27, 2013.
See Pet. Ex. 3 at 26-31. She continued treatment through March 2013 and appeared to have some
improvement; on March 8, 2013, petitioner reported that she was “feeling really good.” Pet. Ex. 3
at 32-35. A few days later, on March 11, 2018, petitioner reported that she did some climbing in
the crawl space of her home and irritated her left shoulder. Id. at 36. She continued to present
regularly through March for care. Id. at 37-43.

        On April 2, 2013, petitioner presented to Dr. Boll complaining of nasal congestion, ear
pain, and sinus pressure. Pet. Ex. 4 at 6. She was diagnosed with acute sinusitis and prescribed
amoxicillin. Id. at 8. The record does not reflect any complaints of shoulder pain.

        Petitioner continued to present for chiropractic care through April 2013. Pet. Ex. 3 at 45-
54. On April 22, 2013, petitioner reported that she was having left jaw pain which began in April
2012, “about the same time when L shoulder pain came about.” Id. at 53. Her left arm and shoulder
pain were improving, and she wished to continue treatment for her left shoulder. Id. She returned
regularly for treatment through May and June 2013. Id. at 55-66. During an appointment on June
5, 2013, Dr. Cleofe noted that petitioner’s left shoulder was improving and less painful; petitioner
reported that she was able to swing a golf club. Id. at 61. On July 29, 2013, Dr. Cleofe wrote that
petitioner had discontinued treatment but returned, reporting that “she may have exacerbated her
condition after doing planks a few months ago.” Id. at 67. She also reported some pain after 18
holes of golf. Id. at 68. Dr. Cleofe recommended an eight-week treatment plan. Id. at 67.

      An MRI of petitioner’s left shoulder was performed on August 21, 2013 and revealed
“minimal heterogeneous change within the supraspinatus tendon” with no evidence of tear of any



                                                  6
rotator cuff tendons. Pet. Ex. 3 at 23. The impression was “[t]endinopathy…within the
supraspinatus tendon.” Id. at 24.

         Petitioner regularly presented for chiropractic care through August, September, and
October of 2013. See Pet. Ex. 3 at 67-88. At an appointment on November 22, 2013, petitioner
reported to Dr. Cleofe that she had not been doing her shoulder exercises, and had reaggravated
her left shoulder one week earlier, when she reached to catch something and felt severe pain in her
left shoulder. Id. at 89. Petitioner continued to receive chiropractic care through 2017. See id. at
90-189.

       The remainder of petitioner’s medical records are not relevant to the issue of onset.

C.     Statements Prepared for Litigation

       1. Petitioner

        Petitioner submitted a letter dated April 2015 but signed and notarized on August 7, 2017.
Pet. Ex. 8 at 2, 6. Petitioner stated, “…from the moment the [Tdap] shot was given I was
experiencing pain at the injection site.” Id. at 2. She stated that within 24 to 48 hours of receiving
the Tdap vaccination, she called Dr. Boll’s office to speak with him or a nurse about her symptoms
and was advised to use over the counter medication and ice. Id. Petitioner explained that she has
experienced pain with injections in the past, so she “just assumed that this was a normal thing
when getting a shot.” Id. Petitioner stated that she continued to experience pain and it began to
radiate from her shoulder to her neck and jaw. Id. She stated that she had difficulty making an
appointment due to working full-time. Id. Petitioner opted to use over the counter medication to
alleviate pain, but they were not helping. Id. at 2-3. Petitioner wrote:

       I discussed my pain, symptoms and problems with my family and finally made the
       decision to go see my primary care doctor, Dr. Robert Boll once again on February
       27, 2012 to discuss the symptoms I had still continue to be experiencing (sic) since
       receiving the Tdap vaccine at his office.

Id. at 3. Petitioner described seeking treatment with a neurologist and an orthopedist before
deciding to treat with Dr. Cleofe. Id. at 3-5. She stated that she was diagnosed with “symptoms of
frozen shoulder, adhesive capsulitis and shoulder bursitis” and “the MRI also indicated that there
was a partial tear and inflammation around the deltoid muscle and/or overlying tendons which
could be the cause of tendonitis.” Id. at 5. None of these conditions were found in the medical
records that have been filed.

       2. Dr. Boll

        Dr. Boll submitted a letter dated May 18, 2017. Pet. Ex. 7 at 1. He stated that petitioner
received a Tdap vaccine in his office on February 2, 2012 and over the next 24 to 48 hours, her
arm and shoulder near the vaccine site became swollen and painful. Id. He stated that she called
his office and spoke with a nurse about her symptoms, and over the counter medication and ice
were suggested. Id. Dr. Boll further stated, “…when [petititioner] saw me for other matters on



                                                  7
February 27, 2012, we discussed the pain she continued to have in her arm.” Id. At that time, he
referred her to a neurologist. Id. Dr. Boll noted that he saw petitioner again on June 13, 2012, and
she still had shoulder pain. Id.

        Dr. Boll clarified that, when he wrote this letter, he did not have access to petitioner’s
records to check the accuracy of the dates referenced. Id. The wording of his letter is strikingly
similar to the letter submitted by petitioner.

       3. David Kreis

        Petitioner submitted a letter from Mr. Kreis, a certified athletic trainer and teacher at Carl
Sandburg High School, petitioner’s former employer, on November 7, 2017. Pet. Ex. 8.2 at 1. Mr.
Kreis stated that he recalled petitioner asking for neck and shoulder stretches in mid to late
February 2012 due to tight muscles around her shoulder and neck. Id. Mr. Kreis stated that
petitioner was “having discomfort and soreness while moving her arm and turning her head.” Id.
He showed her three stretches for her neck and three stretches for her arm and shoulder but
recommended that she consult her primary care provider or an orthopedic surgeon if her pain
persisted. Id.

       4. Nancy Cassidy

        Ms. Cassidy, the school nurse at Carl Sandburg High School, submitted a letter dated April
26, 2017. Pet. Ex. 9 at 1. She recalled that petitioner began working in the nurse’s office in 2011
and received a Tdap vaccine in February 2012. Id. Ms. Cassidy stated that “immediately” after
receiving the Tdap vaccine, petitioner had pain in her left shoulder and upper arm. Id. The pain
continued and progressed to petitioner’s neck and head over the next few weeks, at which time
petitioner saw several doctors. Id.

       5. Florine Martin

        Ms. Martin, petitioner’s mother, submitted a notarized letter dated November 21, 2017.
Pet. Ex. 10 at 1. She recalled that petitioner received the Tdap vaccine on February 2, 2012,
because Ms. Martin had recently moved into petitioner’s home following the death of Ms. Martin’s
husband. Id. Ms. Martin recalled that petitioner reached out to the doctor’s office and spoke to the
nurse on duty about her pain. Id. The nurse suggested ice and Tylenol or Advil. Id. Ms. Martin
stated, “Over the next few days, [petitioner] realized that the pain was starting to spread to her
neck and shoulder area…”. Id. Ms. Martin recalled petitioner discussing her arm pain with Ms.
Cassidy and one of the personal trainers at school. Id. Ms. Martin stated, “After several months
had gone by and [petitioner] was not getting any better she finally decided to set up an appointment
with a chiropractor…”. Id.

       6. Wayne Clavio

       Mr. Clavio, petitioner’s husband, submitted a notarized letter dated November 21, 2017.
Pet. Ex. 11 at 1. He stated that on the evening of February 2, 2012, after receiving the Tdap
vaccination, petitioner mentioned that her arm was hurting. Id. Mr. Clavio recalled suggesting that



                                                  8
petitioner speak with the school nurse, Nancy, the next day. Id. He recalled that petitioner
discussed it with Ms. Cassidy the next day and called Dr. Boll’s office “when the pain continued
to persist.” Id. He stated that petitioner’s pain progressed over time, and he had to help her with
dressing and undressing. Id.

       7. Yolanda Kolliniatis

        Ms. Kolliniatis submitted a notarized letter dated December 2017. Pet. Ex. 12 at 1. She
worked with petitioner at Carl Sandburg High School from 2000 to 2014. Id. Ms. Kolliniatis
recalled that petitioner struggled with pain “immediately after receiving the vaccine.” Id. Ms.
Kolliniatis and petitioner used to spend their lunch breaks together; Ms. Kolliniatis recalled
petitioner calling the doctor’s office as well as her daughter, a nurse, during their breaks to discuss
her pain “for the days and weeks following the immunization.” Id. Ms. Kolliniates stated, “In spite
of attempts with pain medication for relief, the pain quickly progressed and eventually led to
decreased motion of her left arm and shoulder.” Id.

       8. Jeannie Murawski

        Ms. Murawski submitted a notarized letter dated December 22, 2017; at that time, she was
living in Georgia. Pet. Ex. 13 at 1. Ms. Murawski has been friends with petitioner “since the 70s.”
Id. Ms. Murawski recalled that, after petitioner received the Tdap vaccination, she “immediately”
had “stiffness and difficulty raising or moving her left arm.” Id. Ms. Murawski stated, “I believe
they told her that depending on where or how the injection was placed in her arm, there might be
a problem.” Id. Ms. Murawski explained that she recalled these details because she was carjacked
in March 2012, and “hated to give [petitioner] anything else to be upset or concerned with as I
knew she was suffering daily with the pain in her shoulder and left arm.” Id.

                                            II. Discussion

A.     Legal Standards Regarding Fact Finding

        Petitioner bears the burden of establishing her claims by a preponderance of the evidence.
§ 13(a)(1). A petitioner must offer evidence that leads the “trier of fact to believe that the existence
of a fact is more probable than its nonexistence before [he or she] may find in favor of the party
who has the burden to persuade the judge of the fact’s existence.” Moberly v. Sec’y of Health &
Human Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (citations omitted).

        The process for making determinations in Vaccine Program cases regarding factual issues,
such as the timing of onset of petitioner’s alleged injury, begins with analyzing the medical
records, which are required to be filed with the petition. § 11(c)(2). Medical records created
contemporaneously with the events they describe are presumed to be accurate and “complete” such
that they present all relevant information on a patient’s health problems. Cucuras v. Sec’y of Health
& Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993). This presumption is based on the linked
proposition that (i) sick people visit medical professionals; (ii) sick people honestly report their
health problems to those professionals; and (iii) medical professionals record what they are told or
observe when examining their patients in an accurate manner, so that they are aware of enough



                                                   9
relevant facts to make appropriate treatment decisions. Sanchez v. Sec’y of Health & Human Servs.,
No. 11-685V, 2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr. Apr. 10, 2013); Cucuras v. Sec’y of
Health & Human Servs., 26 Cl. Ct. 537, 543 (1992), aff’d, 993 F. 2d. 1525 (Fed. Cir. 1993) (“[i]t
strains reason to conclude that petitioners would fail to accurately report the onset of their
daughter’s symptoms. It is equally unlikely that pediatric neurologists, who are trained in taking
medical histories concerning the onset of neurologically significant symptoms, would consistently
but erroneously report the onset of seizures a week after they in fact occurred”). In making
contemporaneous reports, “accuracy has an extra premium” given that the “proper treatment
hang[s] in the balance.” Id. A patient’s motivation for providing an accurate recount of symptoms
is more immediate, as opposed to testimony offered after the events in question, which is
considered inherently less reliable. Reusser v. Sec’y of Health & Human Servs., 28 Fed. Cl. 516,
523 (1993); see Murphy v. Sec’y of Health & Human Servs., 23 Cl. Ct. 726, 733 (1991), aff'd, 968
F.2d 1226 (Fed. Cir. 1992) (citing United States v. U.S. Gypsum Co., 333 U.S. 364, 396 (1948)).
Contemporaneous medical records that are clear, consistent, and complete warrant substantial
weight “as trustworthy evidence.” Cucuras, 993 F.2d at 1528. Indeed, “where later testimony
conflicts with earlier contemporaneous documents, courts generally give the contemporaneous
documentation more weight.” Id. Similarly, contemporaneous medical records may be considered
more persuasive than a petitioner’s affidavit created years after the fact. See Gerami v. Sec’y of
Health & Human Servs., No. 12-442V, 2013 WL 5998109, at *4 (Fed. Cl. Spec. Mstr. Oct. 11,
2013), mot. for rev. denied, 127 Fed. Cl. 299 (2014) (finding that contemporaneously documented
medical evidence was more persuasive than the letter prepared for litigation purposes).

        In order to overcome the presumption of accuracy afford to contemporaneous medical
records, witness testimony must be “consistent, clear, cogent and compelling.” Sanchez v. Sec’y
of Health & Human Servs., No. 11-685V, 2013 WL 1880825, at *3 (Fed. Cl. Spec. Mstr. Apr. 10,
2013) (quoting Blutstein v. Sec’y of Health & Human Servs., No. 90-2808V, 1998 WL 408611, at
*85 (Fed. Cl. Spec. Mstr. June 30, 1998)). However, a special master cannot make a finding of
fact based on witness testimony alone; the testimony must have some form of corroborating
evidence. See Epstein v. Sec’y of Health & Human Servs., 35 Fed. Cl. 467, 468 (1996) (“In cases
in which a court has based a finding upon lay testimony, there must be corroborating evidence,
either medical or otherwise, to support the claim”).

B.     Determination of Onset

        The onset of petitioner’s alleged shoulder injury is consistently documented as April of
2012, approximately two months after petitioner received the allegedly causal Tdap vaccine. See
Pet. Ex. 4 at 9; Pet. Ex. 5 at 10. Petitioner claimed that the onset of her shoulder pain occurred
within 48 hours of her Tdap vaccination. Motion at 10. She argued that her medical records are
incorrect and submits that the witness statements proffered in support of her claim, combined with
a February 11, 2013 record from her chiropractor, Dr. Cleofe, constitute sufficient support for her
claim, and should be given greater weight than the records documenting onset of April 2012. Id.
at 9-10.

        Respondent asserted that the contemporaneous medical records consistently place the onset
of petitioner’s shoulder pain in April 2012 and cannot be overcome by the evidence proffered by
petitioner. Response at 1, 8. Respondent pointed out that petitioner did not initially connect her



                                                10
shoulder pain to the Tdap vaccine and repeatedly “denied any known injury” to her left shoulder
to multiple medical providers. Id. at 9-10. Respondent further asserted that the witness statements
from petitioner’s friends and family should be given little evidentiary weight because they are not
sworn statements and “do not provide a credible and reliable basis to set aside petitioner’s medical
records” due to a lack of foundation for the recollections provided therein. Id. at 11-13.

          In her Reply, petitioner repeated her assertion that Dr. Cleofe’s record corroborates her
claim and should be given great weight. Reply at 3. She cites a fact ruling on a SIRVA claim,
Tenneson v. Sec’y of Health & Human Servs., No. 16-1664V, 2018 WL 3083140 (Fed. Cl. Spec.
Mstr. March 30, 2018), submitting that the facts are sufficiently similar to the instant matter so as
to dictate a ruling in petitioner’s favor. Reply at 4-6. Petitioner further submitted that her denials
of “any known injury” should be disregarded, as she would not identify a vaccination as an
“injury.” Id. at 6-7. Additionally, petitioner appeared to argue that respondent has waived his right
to dispute the facts pertaining to onset, stating“[i]f respondent wishes to challenge Dr. Boll’s
recollection as to whether these events happened, otherwise challenge the recollection of any of
the other fact witnesses . . . he should insist on the opportunity to cross examine them under oath
. . . [otherwise] the Special Master should accept their fact statements/affidavits as true.” Reply at
8-9.

        For the reasons outlined below, I find that the onset of petitioner’s left shoulder pain was
in April 2012.

       1. The contemporaneous medical records support an onset in April 2012

        Petitioner “urge[d] the Special Master to give greater weight to the statements of the
petition and the seven other declarants affiants (sic) than to the omission of onset information in
the medical records.” Motion at 9. In support of her position, petitioner submitted that there is a
missing record of a telephone call to Dr. Boll made between 24 and 48 hours of vaccination and
missing information from an appointment on February 27, 2012.

        Petitioner stated that, within 24 to 48 hours of receiving the Tdap vaccination, she called
Dr. Boll’s office to complain of shoulder pain and spoke to a nurse, who recommended ice and
over the counter medication. Pet. Ex. 8 at 1. None of the medical records from Dr. Boll’s office
reflect such a call. According to petitioner, “it is not clear whether the office even maintained
records of telephone calls from patients.” Motion at 5. Dr. Boll submitted a statement reiterating
that petitioner called and spoke to a nurse. Pet. Ex. 7 at 1. He did not address whether telephone
calls from patients were routinely documented. Several of petitioner’s other witnesses, including
Ms. Kolliniatis, Ms. Murawski, Ms. Martin, and Mr. Clavio, state that petitioner called Dr. Boll’s
office about her shoulder pain. See Pet. Ex. 10 at 1 (Petitioner’s mother stated, “As the hours
passed and the pain was increasing I do recall that Maureen had reached out to her doctor’s office
and had complained to the nurse on duty of the pain she was feeling.”); Pet. Ex. 11 at 1 (Petitioner’s
husband stated, “The next day Maureen…called Dr. Boll’s office when the pain continued to
persist.”); Pet. Ex. 12 at 1 (Petitioner’s co-worker recalled “several calls during our lunch breaks
immediately after the vaccine was given to both her doctor’s office and to her daughter…”); Pet.
Ex. 13 at 1 (Petitioner’s friend stated, “I know that she contacted her Physician [sic] right away to
ask if these symptoms might have something to do with the TDAP injection.”). The statements



                                                 11
submitted by Dr. Boll and petitioner’s other witnesses were made years after the telephone call in
question. Neither Dr. Boll nor petitioner’s friends or family noted having witnessed this telephone
call, but rather were told that it happened after the fact.

        In his statement, Dr. Boll recalled that he and petitioner discussed her arm pain at an
appointment on February 27, 2012, even though this is not reflected in the record for this
appointment, but his record does reflect complaints of pain in her ear and the left side of her face.
Petitioner submits that, per Murphy v. Sec’y of Health & Human Servs., this correction by Dr. Boll
should be considered persuasive. 23 Cl. Ct. 726, 733 (1991), aff’d per curiam, 968 F.2d 1226 (Fed.
Cir. 1992) (“If a record was prepared by a disinterested person who later acknowledged that the
entry was incorrect in some respect, the later correction must be taken into account.”). However,
the records indicate that on this date, petitioner was seen by a nurse practitioner, Maya Karam, not
Dr. Boll. As Dr. Boll himself admitted, he did not review petitioner’s medical records to check the
accuracy of his dates. It seems more likely that Dr. Boll based his letter on facts relayed to him by
petitioner. It strains reason that Dr. Boll, a primary care physician who undoubtedly conducts
hundreds of patient office visits per year, would remember a specific visit with petitioner four
years later, particularly without consulting medical records, especially since the doctor did not see
the patient on that date.

        Respondent submitted that petitioner gave no explanation as to why all of her medical
records reflect an onset of shoulder pain in April 2012, yet argues that all of her records are
incorrect, “which lacks credibility, as at least three different doctors all reported the same onset
date of April 2012 in their records based on petitioner’s contemporaneous statements.” Response
at 11, citing Pet. Ex. 4 at 9, 32; Pet. Ex. 2 at 4.

        To further support his assertion that petitioner’s medical records support an onset of
shoulder pain in April 2012, respondent pointed out “petitioner states that she also developed jaw
pain when her left shoulder symptoms began, and her dental records note that she first sought care
for that condition in May 2012.” Response at 10, citing Pet. Ex. 6 at 1. Petitioner echoed this
statement during an appointment with Dr. Cleofe on April 22, 2013, when she reported that her
jaw pain began in April 2012, around the same time as her left shoulder pain. See Pet. Ex. 3 at 53.

        Respondent also cited to petitioner’s visit with Dr. Boll on June 13, 2012, where petitioner
denied sustaining any injury, and an appointment with Dr. Regan on June 18, 2012, where
petitioner stated that her left shoulder pain had a “spontaneous onset.” Pet. Ex. 4 at 9 (Petitioner’s
chief complaint listed as “c/o pain to L UE radiating to L lat neck/L temporal area x2 months,
denies injury”); Pet. Ex. 2 at 3 (“She is having trouble with her left temple and down into her
shoulder. She has been treating this conservatively with spontaneous onset.”).

        Petitioner responded that she would not have identified a vaccination as an “injury.” Reply
at 6. In petitioner’s interpretation, “injury…most likely means falling off a bike or accidentally
getting hit with a golf club, not the administration of a vaccine…” Id. at 7. However, if petitioner
had experienced shoulder pain within 24 to 48 hours of vaccination, then it would be expected that
she would connect that shoulder pain to the vaccine, even if she would typically not identify it as
an “injury.”




                                                 12
       2. Dr. Cleofe’s record does not support an onset in February 2012

        Petitioner relied heavily on a record from an appointment with Dr. Cleofe, a chiropractor,
on February 11, 2013, when she presented with chronic left shoulder pain to support her claim of
onset in February 2012. Motion at 3; Pet. Ex. 3 at 1. Petitioner submitted that Dr. Cleofe “found a
possible precipitating cause was ‘TDAP injection in April 2012?’[sic].” Motion at 3, citing Pet.
Ex. 3 at 1. Petitioner asserted, “This record clearly associates the onset of petitioner’s pain with
her vaccination although it admittedly does not tell exactly when that pain began.” Reply at 3.
Petitioner then clarified that, in another part of the record, “Dr. Cleofe specifically noted, “she
cannot report any other specific trigger factor for the pain except that she had a TDAP Shot in her
L shoulder 1 day prior to all the pain starting.” Id., citing Pet. Ex. 3 at 1 (emphasis omitted).
Petitioner concluded, “The two references in Dr. Cleofe’s record of February 11, 2013, especially
when read together, provide clear and convincing medical record corroboration for petitioner’s
affidavit and the statements of the other seven declarants.” Id. Petitioner further asserted that Dr.
Cleofe’s record from February 2013 should be given “great weight” because it “was not created
for purposes of litigation, nor at a time when SIRVA was a known injury.” Id.

        When examined in further detail, Dr. Cleofe’s record does not support an onset of shoulder
pain in February 2012. Dr. Cleofe did not examine petitioner until a year after her Tdap
vaccination, approximately eight months after her first documented complaint of shoulder pain.
At this appointment, petitioner initially reported that in April 2012, she woke up with pain in her
left temple and later noticed it in her left arm and neck. See Pet. Ex. 3 at 11. She did not connect
her shoulder pain with the Tdap vaccine until Dr. Cleofe asked her about any possible
precipitating events. Id. at 2, 11. She then provided an inaccurate history, stating that she received
a Tdap vaccine in April 2012, rather than February. Petitioner’s consistent reporting of shoulder
onset in April of 2012 is telling.

       3. The witness statements proffered by petitioner lack foundation

        Respondent submitted that the witness statements offered by petitioner should be given
little weight because they are unsworn and do not “contain the required language for statements
given under oath.” Response at 11. While respondent is correct that the witness statements do not
meet the criteria articulated in 28 U.S.C. § 1746, the Vaccine Program was designed to have
“flexible and informal standards of admissibility of evidence.” 42 U.S.C. § 300aa-12(d)(2)(B); see
also Munn v. Sec’y of Health & Human Servs., 970 F.2d 863, 873 (Fed. Cir. 1992) (finding that
the Federal Rules of Evidence are inapplicable in Vaccine Act proceedings); Stevens v. Sec’y of
Health & Human Servs., 31 Fed. Cl. 12, 20-21 (1994) (special master correctly concluded that the
Federal Rules of Civil Procedure do not apply to proceedings under the Vaccine Act). It would be
counterpoint to these purposefully relaxed standards to require witness statements to meet the
statutory requirement for unsworn statements in order to be given any significant evidentiary
weight.

        However, respondent correctly pointed out that most of petitioner’s witnesses do not
provide a foundation for the basis of their recollections. Response at 12-13. Petitioner submitted
that Florine Martin and Jeannine Murawski connected their memories to significant life events.



                                                 13
Ms. Martin stated that she recalled the onset of petitioner’s injury because Ms. Martin’s husband
“had recently passed away” and Ms. Martin had moved in with petitioner. However, Ms. Martin
did not provide any specific dates for when her husband passed or when she moved in with
petitioner. Ms. Murawski stated that she recalled the onset of petitioner’s injury because she was
the victim of a carjacking in March of 2012 and did not want to burden petitioner with this news
due to her shoulder injury.

        “It is the court’s experience that people tend to recall events in connection with holidays
or days of special significance such as birthdays or anniversaries. In fact, a recollection tied to such
an event often lends credibility to the particular remembrance.” O’Leary v. Sec’y of Health &
Human Servs., 1998 WL 218224 at *8 (Fed. Cl. Spec. Mstr. Apr. 17, 1998). While Ms. Murawski
provided a significant event and specified the month in which it occurred, Ms. Martin did not
provide the time frame in which her husband’s death occurred. Conversely, Dr. Mayer noted
during petitioner’s appointment on June 29, 2012, that petitioner specifically connected the onset
of her pain “around Easter time in April” Pet. Ex. 4 at 32. Respondent noted that, in 2012, Easter
fell on April 8. Response at 3, n.1. Petitioner’s consistent reporting to various unrelated medical
providers that the onset of her left shoulder pain was in April around Easter lends credence to the
significance of holidays and memory.

       4. Tenneson is distinguishable from the instant matter

         Petitioner cited to Tenneson v. Sec’y of Health & Human Servs., No. 16-1664V, 2018 WL
3083140 (Fed. Cl. Spec. Mstr. March 30, 2018) for support. In Tenneson, the first documentation
of Ms. Tenneson’s shoulder pain occurred approximately six months after she received the
allegedly causal vaccination. Id. at *5. During the six-month period between vaccination and
documentation of shoulder pain, Ms. Tenneson had presented to the emergency room for kidney
stones and had not complained of shoulder pain. Id. The special master found that Ms. Tenneson
had an onset of shoulder pain within 48 hours of vaccination based on affidavits from Ms.
Tenneson, her husband, and her son, combined with medical records indicating that, when Ms.
Tenneson did seek medical care for her shoulder pain, she reported that she had had arm pain since
the flu shot. Id. at *5-6. She gave the same history to a physical therapist the following month. The
special master found that Ms. Tenneson “repeatedly and consistently placed the onset of her
condition within 48 hours of vaccination.” Tenneson at *5.

        Upon review, the Court of Federal Claims affirmed the special master’s decision, noting
that the special master cited to medical records in which petitioner consistently placed the onset of
her shoulder pain directly after the vaccination. Tenneson v. Sec’y of Health & Human Servs., 142
Fed. Cl. 329, 338 (2019). The Court of Federal Claims agreed with the special master’s finding
that the emergency room where petitioner did not mention her shoulder pain was not disqualifying;
the Court noted, “After all, the purpose of an emergency room visit is to receive emergency
treatment, not a comprehensive health check-up.” Id. at 340.

       The instant matter is distinguishable from Tenneson. In Tenneson, the medical visit that
occurred between vaccination and the petitioner’s first documented report of shoulder pain was an
emergency room visit for kidney stones. It was reasonable that the petitioner did not report her
shoulder pain when the purpose of her visit to the emergency room was to receive treatment for



                                                  14
kidney stones and her debilitating condition. Here, petitioner received the Tdap vaccination on
February 2, 2012, from her primary care provider; on February 27, 2012, she returned to her
primary care practice with complaints of nasal congestion, sore throat, non-productive cough, ear
pain, and pain on the left side of her face and teeth. Petitioner did not report left shoulder pain at
this appointment.

        Petitioner submitted that her situation is similar to Tenneson because she presented to her
primary care practice for an acute illness, noting that she was diagnosed with sinusitis and
prescribed an antibiotic. Motion at 7. Unlike Tenneson, however, petitioner returned to the doctor
who administered the vaccine and reported sinusitis and pain in her ear and left side of her face. It
follows that someone returning to the doctor who administered an allegedly causal vaccine in a
non-emergent situation would be more likely to mention shoulder pain, if it existed, than someone
in Ms. Tenneson’s position. Accordingly, it appears petitioner would have mentioned her shoulder
pain, if it had been present, at her February 27, 2012 visit. Her failure to mention any such pain
bolsters the conclusion that onset of her pain began in April of 2012.

       5. Petitioner must prove onset by a preponderance of the evidence

       In submitting that respondent must request cross-examination of witnesses in order to
challenge the reliability of their statements, petitioner incorrectly placed the burden on respondent
to disprove petitioner’s proffered facts, when it is petitioner’s burden to prove the factual
circumstances surrounding her claim by a preponderance of the evidence. 42 U.S.C. § 300aa-
13(a)(1)(A); see also 42 U.S.C. § 300aa-13(b)(2) (“[t]e special master or court may find the first
symptom or manifestation of onset…occurred within the time period described in the Vaccine
Injury Table even though the occurrence of such symptom or manifestation was not recorded or
was incorrectly recorded as having occurred outside such period. Such a finding may be made only
upon demonstration by a preponderance of the evidence that the onset…did in fact occur within
the time period described in the Vaccine Injury Table.”).

        Petitioner further stated that she “is happy to provide the statements in the form of sworn
affidavits if the Special Master indicates that his is an important consideration. Alternatively, the
Special Master can conduct a fact hearing and the witnesses can testify under oath.” Reply at 7.
Petitioner had the opportunity to request a fact hearing and instead chose to pursue a factual ruling
based on the record. It is inappropriate for petitioner to imply that she would have chosen to
proceed to a hearing, if only she had known that respondent would question the reliability of her
witnesses. If respondent agreed with petitioner that her witnesses were reliable and accurate
historians, then respondent would not have questioned onset but would have instead accepted the
proffered witness statements as persuasive evidence.

       6. Onset occurred in April 2012

        Petitioner’s affidavit and witness statements are insufficient to overcome the presumption
of accuracy afforded to contemporaneous medical records. Petitioner’s medical records indicate
that she was vigilant about her health; she had yearly bloodwork done at her place of employment,
which she then faxed to Dr. Boll and requested follow-up calls to discuss her results. When she
was sick or had pain, she went to the doctor. This is evidenced by the records of the treatment she



                                                 15
sought for her left hip and left knee pain. Once petitioner began seeking treatment for her left
shoulder pain, she consistently presented for care with multiple physicians, physical therapy, and
then chiropractic care as many as three times per week. Based on the contemporaneous medical
records, the onset for petitioner’s left shoulder pain appears to be April 2012, based on petitioner’s
presentation to Dr. Boll on June 13, 2012, when she reported left shoulder pain for two months.
Onset in April 2012 is supported by petitioner’s report to Dr. Mayer that her shoulder pain began
around Easter, which was on April 8 that year, and by petitioner’s report to Dr. Cleofe that her jaw
pain began in April 2012, around the same time as her left shoulder pain.

                                          III. Conclusion

       Upon detailed review of the record, I find that petitioner’s left shoulder pain began in April
of 2012. Petitioner has 30 days to submit a status report indicating how she intends to proceed.

       Accordingly, the following is ORDERED:

               Petitioner’s status report is due by no later than Friday, April 10, 2020.

       IT IS SO ORDERED.



                                                      s/ Mindy Michaels Roth
                                                      Mindy Michaels Roth
                                                      Special Master




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