Adhesive Capsulitis After Vaccination: SIRVA or Coincidence?
Updated: Aug 10
Adhesive capsulitis is one of the most frequently discussed diagnoses in the SIRVA literature.
Patients typically present with progressive shoulder pain and restriction of both active and passive range of motion. In classic primary adhesive capsulitis, symptoms often develop gradually and may persist for many months. In contrast, some reports of post-vaccination adhesive capsulitis describe a much more abrupt onset, often beginning within hours or days after vaccination.
That difference has led some authors to classify post-vaccination adhesive capsulitis as a manifestation of Shoulder Injury Related to Vaccine Administration (SIRVA).
Others are more cautious. The evidence base contains case reports, small case series, and observational cohorts, but relatively little high-level comparative evidence. In 2024, the National Academies concluded that the available evidence was inadequate to accept or reject a causal relationship between vaccine administration and adhesive capsulitis.
So which interpretation is most defensible? The answer depends heavily on the individual presentation.
Key Takeaways
Adhesive capsulitis has been reported after influenza, pneumococcal, HPV, and COVID-19 vaccination.
Some cases begin within 24–48 hours, closely matching traditional SIRVA timing.
Other series report onset substantially later, including a mean of 12.3 days in the Ghosh series.
Several plausible mechanisms have been proposed, including inadvertent injection into periarticular tissues, local immune-mediated inflammation, subsequent capsular fibrosis, and immobilization related to post-injection pain.
The published evidence does not establish that all adhesive capsulitis appearing after vaccination is vaccine caused.
Timing, prior shoulder status, established frozen-shoulder risk factors, injection technique, imaging, and alternative explanations remain critical to individual causation analysis.
Adhesive Capsulitis Is Not Unique to Vaccination
Frozen shoulder is a common clinical disorder unrelated to vaccination.
Its underlying biology remains incompletely understood, but the process involves both inflammation and fibrosis of the glenohumeral capsule. Ghosh and colleagues summarized a range of implicated inflammatory mediators and immune cells, including interleukins, tumor necrosis factor, cyclooxygenase pathways, matrix metalloproteinases, lymphocytes, mast cells, and macrophages.
This matters because a patient can develop adhesive capsulitis after vaccination for at least two very different reasons:
vaccination may have contributed to its development
or
the condition may have occurred coincidentally after vaccination.
Temporal sequence alone cannot reliably distinguish the two.
Why Is Adhesive Capsulitis Considered Part of SIRVA?
The proposed SIRVA mechanism offers a biologically plausible pathway.
If a vaccine intended for the deltoid is administered too high or too deeply, the needle may reach tissues beneath the deltoid, including the subacromial-subdeltoid bursa or other periarticular structures.
Foong and colleagues note that the subacromial bursa can lie relatively close to the skin, making it potentially susceptible to penetration when vaccination is performed too proximally or too deeply. They proposed that vaccine material introduced into synovial tissues could trigger localized inflammation associated with bursitis, tendinitis, rotator cuff abnormalities, and adhesive capsulitis.
A second possible pathway is indirect.
Pain following vaccination may lead patients to reduce shoulder use. Foong et al. proposed that prolonged guarding or immobilization, combined with local inflammation, could further predispose to capsular stiffness and fibrosis.
These mechanisms are plausible. But biological plausibility is not the same thing as proof of causation.
The Strongest Cases: Symptoms Beginning Within 24–48 Hours
Some published adhesive capsulitis cases closely resemble traditional SIRVA.
A case reported by Aldosary reported symptoms beginning within 24 hours of the vaccination, and a Biglia case reported symptoms starting within 48 hours.
Biglia and colleagues described a 50-year-old woman who developed adhesive capsulitis together with subacromial/subdeltoid fibroadhesive bursitis 48 hours after her second COVID-19 vaccination. Ultrasound-guided capsular and bursal hydrodistension followed by exercise resulted in near-complete improvement in pain and motion.
From a causation perspective, this type of presentation is more compelling because several elements align:
previously functional shoulder,
short latency,
ipsilateral symptoms,
inflammatory periarticular pathology,
and development of capsular restriction.
It still does not prove causation, but it resembles the classic SIRVA phenotype more closely than a frozen shoulder developing weeks or months later.
Sahu and Shetty reported 10 cases of frozen shoulder after COVID-19 vaccination.
The cohort had a mean age of 53.8 years and included nine women and one man. Importantly, four patients had diabetes or prediabetes and four had hypothyroidism, both clinically relevant because these are established associations with adhesive capsulitis.
This illustrates an important causation issue. Early temporal onset supports a potential relationship.
But the presence of underlying frozen-shoulder risk factors complicates attribution. A patient can have both:
a predisposition to adhesive capsulitis
and
a plausible vaccine-related trigger.
Those possibilities are not mutually exclusive.
Later-Onset Cases Are More Difficult to Classify
The Ghosh case series is particularly important because the authors themselves questioned whether their cases should simply be labeled SIRVA.
They reported nine patients with adhesive capsulitis after Covishield vaccination. Their patients had restricted active and passive motion, normal radiographs, persistent symptoms, and no apparent trauma or other secondary cause.
However, symptom onset was substantially later than traditional SIRVA. Individual onset times in the series ranged from approximately 4 to 17 days, with a mean of 12.3 ± 3.1 days.
This is why Ghosh and colleagues explicitly stated that they were reluctant to label all of these cases SIRVA. Their patients had definite adhesive capsulitis without associated rotator cuff pathology, but the later onset made the traditional SIRVA explanation less straightforward.
That caution is scientifically important.
It would be misleading to treat a shoulder becoming painful 12 days after vaccination as temporally equivalent to one becoming painful during the injection or the following morning.
Mülkoğlu et al. reported another observational series included 21 patients with adhesive capsulitis after COVID-19 vaccination. The patients in this cohort had no pre-vaccination shoulder pain and developed new pain and restriction after vaccination.
The mean onset reported in our extraction dataset was approximately 8 days, again later than the classic ≤48-hour SIRVA interval. The authors nevertheless considered adhesive capsulitis after vaccination within the broader SIRVA spectrum and discussed several possible mechanisms: autoimmune or inflammatory capsular involvement, antigen-antibody response following deposition into the subacromial/subdeltoid bursa, overpenetration, and incorrect injection technique.
The study demonstrated significant improvement following conventional adhesive capsulitis treatment, but it lacked a control group and had relatively short follow-up, limitations acknowledged by the authors themselves.
Thus, the study demonstrates that adhesive capsulitis can occur in temporal association with vaccination, but it cannot determine how many of those cases were actually caused by vaccination.
Some Reported Cases Begin Months Later
The farther symptom onset moves from vaccination, the more difficult causal attribution becomes.
The National Academies review identified reported frozen shoulder cases beginning months after vaccination, including one following Moderna vaccination with symptom onset at approximately four months. Other reports diagnosed frozen shoulder months to years after influenza or pneumococcal vaccination.
The committee specifically emphasized that adhesive capsulitis is often diagnosed late and that attribution becomes increasingly difficult when many months or years separate vaccination and diagnosis because numerous confounding factors can intervene.
This is a critical distinction: date of diagnosis is not necessarily date of symptom onset.
A patient can develop pain immediately and not receive a formal diagnosis of adhesive capsulitis until months later.
Therefore, the relevant temporal variable is when the symptoms began, not when someone finally wrote “adhesive capsulitis” in the medical record.
But if the symptoms themselves did not begin for months, a classic SIRVA mechanism becomes far more difficult to support.
Post-Vaccination Frozen Shoulder May Not Behave Exactly Like Idiopathic Frozen Shoulder
Another interesting line of evidence comes from work comparing post-vaccination frozen shoulder with idiopathic frozen shoulder.
Foong et al. noted that patients with post-vaccination adhesive capsulitis tended to describe a more acute onset, whereas primary adhesive capsulitis generally develops more gradually. They proposed that an acute local inflammatory event after injection may account for the difference.
That observation is potentially important because rapid onset is less typical of conventional idiopathic adhesive capsulitis.
However, observational differences between small groups cannot establish that vaccination caused the condition.
They can, at most, help define a potential phenotype worthy of further study.
What About Patients With Diabetes or Thyroid Disease?
This is one of the most important issues in individual causation analysis.
Adhesive capsulitis is associated with several systemic risk factors, particularly:
diabetes,
prediabetes,
thyroid disease,
prior adhesive capsulitis,
prolonged immobilization,
and some other metabolic or inflammatory disorders.
In the Sahu cohort, 4 of 10 patients had diabetes or prediabetes and 4 had hypothyroidism. The presence of one of these conditions should not automatically exclude a vaccine-related contribution.
But it does provide a competing biological explanation and changes the strength of causal inference.
For example, a diabetic patient with gradual shoulder stiffness developing three weeks after vaccination presents a substantially different causation problem from a patient without known risk factors who develops severe shoulder pain during injection and marked capsular restriction soon thereafter.
Ghosh and colleagues specifically selected patients without known traditional risk factors for adhesive capsulitis. They acknowledged their small sample size and the difficulty of studying a relatively uncommon event, but considered the absence of conventional risk factors one reason their cases deserved attention.
That strengthens the temporal observation somewhat.
But it still does not provide a control population showing that adhesive capsulitis occurred more often than would otherwise have been expected.
That is the limitation shared by most of the current literature.
What Do Systematic Reviews Say?
Systematic reviews have consistently identified adhesive capsulitis among the reported diagnoses following vaccination, including systematic reviews by Wright et al., Slette et al., and others.
However, systematic reviews of case reports remain constrained by the quality of the underlying evidence.
Case reports are particularly vulnerable to:
selection bias,
publication bias,
absence of comparison groups,
incomplete documentation of prior shoulder status,
variable SIRVA definitions,
and attribution based primarily on temporal association.
A systematic review can establish that the phenomenon has repeatedly been reported.
It cannot necessarily establish that vaccination causes adhesive capsulitis at a population level.
The National Academies Conclusion Is Important
The 2024 National Academies evidence review provides perhaps the most appropriately cautious synthesis.
After reviewing the available case evidence, the committee concluded:
the evidence was inadequate to either accept or reject a causal relationship between vaccine administration and adhesive capsulitis.
That is different from saying:
vaccines do not cause adhesive capsulitis.
It is also different from saying:
adhesive capsulitis after vaccination is established SIRVA.
The conclusion is that the available evidence remains insufficient to resolve causality definitively.
So When Is Adhesive Capsulitis Most Consistent With SIRVA?
A presentation is more consistent with the traditional SIRVA framework when several features align:
Previously asymptomatic shoulder
vaccination in the affected shoulder
onset during the first 24–48 hours
pain exceeding ordinary injection soreness
progressive restriction of both active and passive motion
no more persuasive alternative cause
anatomical or clinical evidence compatible with periarticular inflammation.
The strength of inference decreases as those features disappear.
When Does Coincidence Become More Plausible?
Coincidental or idiopathic adhesive capsulitis deserves greater consideration when there is:
substantial delay between vaccination and symptom onset,
gradual onset without an acute post-injection syndrome,
diabetes or thyroid disease,
prior shoulder stiffness,
prior contralateral adhesive capsulitis,
an intervening injury,
prolonged immobilization for another reason,
or another recognized secondary cause.
None of these factors is individually dispositive. The point is to compare the competing explanations.
Could Vaccination Trigger Adhesive Capsulitis Without Directly Injuring the Capsule?
Possibly. A useful way to conceptualize the mechanism is as a sequence:
Injection
→ local inflammatory pain
→ reduced shoulder use
→ progressive capsular inflammation and fibrosis
→ clinical adhesive capsulitis
This differs from the concept of direct needle penetration of the capsule.
Foong and colleagues specifically proposed that post-vaccination pain and guarding may create immobilization that contributes to capsular development, particularly when combined with inflammation or an immunologic response.
This mechanism could theoretically account for cases in which pain begins promptly but the characteristic frozen-shoulder pattern becomes apparent later.
It does not as readily explain a patient who remains entirely asymptomatic for weeks before symptoms begin.
The Timing of Pain and the Timing of Capsular Stiffness Should Be Separated
This is an important clinical distinction.
A patient might experience:
Day 0: acute shoulder pain after injection
Week 1: reduced shoulder use
Weeks 2–6: progressive loss of motion
Month 2: formal diagnosis of adhesive capsulitis
That timeline could be compatible with an acute inciting event followed by secondary capsular fibrosis.
It would be misleading to characterize the “onset” of that case as two months simply because that is when adhesive capsulitis was diagnosed.
The medical record should distinguish:
onset of shoulder pain,
onset of stiffness,
onset of functional limitation,
and date of formal diagnosis.
Treatment Response Does Not Establish Causation
Post-vaccination adhesive capsulitis is generally treated using the same principles applied to conventional frozen shoulder.
Reported treatments include:
NSAIDs,
physical therapy,
intra-articular corticosteroid injection,
suprascapular nerve block,
hydrodilatation,
and home exercise.
But treatment response tells us that the diagnosis and targeted structure were clinically relevant.
It does not establish why the adhesive capsulitis developed.
A Practical Causation Framework
When evaluating adhesive capsulitis after vaccination, six questions are particularly useful:
Was the shoulder symptomatic or restricted before vaccination?
When did pain actually begin—not when was frozen shoulder diagnosed?
Was the onset abrupt or gradual?
Are diabetes, thyroid disease, prior frozen shoulder, immobilization, or other recognized risk factors present?
Was there evidence of high/deep injection or associated bursal/periarticular inflammation?
Is there a more likely alternative explanation for the clinical course?
The answer should come from the combined evidence rather than any single criterion.
The Bottom Line
So, is adhesive capsulitis after vaccination SIRVA or coincidence?
It can plausibly be either.
The literature contains multiple well-described cases of adhesive capsulitis beginning rapidly after vaccination, including cases within 24–48 hours that fit the traditional SIRVA phenotype closely.
It also contains cases with substantially longer latency, traditional frozen-shoulder risk factors, and limited evidence establishing a direct vaccine-related mechanism.
The most appropriate conclusion is therefore not:
“Frozen shoulder after vaccination is SIRVA.”
Nor is it:
“Frozen shoulder is common, so vaccination cannot be causal.”
A more defensible interpretation is:
Adhesive capsulitis is a recognized clinical phenotype reported after vaccination, but individual causation depends on the temporal pattern, prior shoulder status, competing risk factors, injection anatomy, and clinical course. The current literature supports biological plausibility and repeated temporal association, but does not establish a universal causal relationship.
That conclusion is also consistent with the National Academies determination that current evidence remains insufficient to definitively accept or reject causation.
References
Sahu D, Shetty G. Frozen shoulder after COVID-19 vaccination. JSES Int. 2022;6:682-685.
Sahu D, Gupta S, Shetty G, et al. Frozen shoulder after COVID-19 vaccination versus idiopathic frozen shoulder. JSES Rev Rep Tech. 2024;4:41-47.
Ghosh S, Pandey SK, Biswas A, Pandey J. Adhesive capsulitis after COVID-19 vaccination: a case series. Am J Phys Med Rehabil. 2023;102:e79-e82.
Mülkoğlu C, Tiftik T, Deniz AB, Taka İ, Genç H. Analysis of patients with adhesive capsulitis after COVID-19 vaccination: an observational study. Turk J Phys Med Rehabil. 2023;69(4):520-525. doi:10.5606/tftrd.2023.12660.
Foong BCM, Ho SWL, Tan LTJ, Lee KT, Jegathesan T. Adhesive capsulitis secondary to COVID-19 vaccination: a case series. Malays Orthop J. 2023;17(2):43-48. d
Biglia A, Morandi V, Zanframundo G, Donati D, Maggiore F, Vita F, et al. Adhesive capsulitis after COVID-19 vaccine injection: a peculiar case treated with combined bursa distention and glenohumeral capsular hydrodilatation. J Ultrasound. 2023.
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National Academies of Sciences, Engineering, and Medicine. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press; 2024.
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About the Author
Walter I. Sussman, DO, FAAPM&R is a board-certified Sports Medicine and Physical Medicine & Rehabilitation physician.
This article is intended for educational purposes and does not constitute a medical opinion regarding any individual case. Assessment of diagnosis and causation requires review of the specific medical history, records, imaging, and circumstances involved.
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