Received Mar 27, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA MNEXSPIKE)) | MODERNA | 1 | 031M20A | IM / LA |
Patient reports experiencing significant shoulder pain and limited mobility after receiving a COVID-19 vaccination on February 12, 2021. The pain has persisted since that time, gradually improving over time.
HTN, HLD, diabetes type 2
HTN, HLD, diabetes type 2
Losartan, metformin, simvastatin
Lisinopril
He states that the pains started right after getting his first vaccine of the Moderna. He has a history of driving truck for years. He denies any prior trauma to the shoulder. He has taken some NSAIDs but without relief. He has done PT for his left shoulder but this has not helped. An MRI in November 2021 revealed Complete tear of the supraspinatous and infraspinatus tendons. Tendons and muscles are retracted with upward subluxation of the humeral head and narrowing of the subacromial space. The supraspinatous, infraspinatus, and teres minor muscles are atrophied, suggesting that the tear is chronic. Biceps tendon not avulsed but may be partially torn proximally. Joint effusion. Fluid in the subacromial/subdeltoid bursa probably relates to rotator cuff tear. Small cystic areas in the inferior glenoid probably related to degenerative change. Cystic areas at the greater tuberosity probably relate to rotator cuff tendinopathy. He was offered orthopedic surgery but declines at this time