Keith Roach, M.D., syndicated columnist

DEAR DR. ROACH: Two years ago, I received the high-dose flu vaccine at my doctor’s office. It resulted in a severe case of SIRVA bursitis in my shoulder. I suffered for three months, taking Tylenol after getting two shots of steroid from my orthopedic surgeon and physical therapy. Since then I have been afraid to get another vaccine. However, when I broke my elbow, the emergency doctor gave me a tetanus shot, which did not cause any discomfort. Now that a COVID-19 vaccine might become available shortly, I was wondering how the flu shot gave me such a horrible reaction and the tetanus shot didn’t. How can I avoid the experience that I had with the flu shot? — A.L.

ANSWER: Shoulder Injury Related to Vaccine Administration happens when the vaccine is injected too deep in the shoulder. Instead of going into the muscle, the vaccine goes into the shoulder bursa, causing a strong immune reaction. Symptoms usually begin within a few hours of vaccine administration. Three months is a long time, but not unheard of, to have symptoms from SIRVA. Physical therapy and steroid shots are common therapies.

SIRVA can be avoided with proper administration technique. My limited experience with SIRVA suggests that it is more likely in more in people with a slight build, who have less subcutaneous fat and smaller musculature. Some professionals always place the needle to the hub, but in smaller people, that may be too deep. Using a smaller needle or just placing the tip into the middle of the muscle will prevent SIRVA. Tell the doctor, nurse, physician assistant or pharmacist that you have had this problem before and that they need to take extra care with the injection. This is the case with any intramuscular vaccine.

There are several candidate vaccines for SARS-CoV-2, and some are intramuscular while others are subcutaneous, which do not cause SIRVA.