Has Ultrasound Research Changed How SIRVA Is Evaluated?
Potentially, but not to the point that ultrasound can diagnose SIRVA by itself.
Historically, imaging in suspected Shoulder Injury Related to Vaccine Administration (SIRVA) has been dominated by MRI. Published MRI findings include bursitis, rotator cuff pathology, adhesive capsulitis, synovitis, bone marrow edema, and osseous abnormalities. Reviews continue to emphasize that these findings are often nonspecific and must be interpreted in clinical context.
Ultrasound has received considerably less study, and that is beginning to change.
Ultrasound Was Initially Used to Understand the Mechanism
Interestingly, ultrasound played an important role in SIRVA before it was studied as a diagnostic modality.
In their foundational 2007 report, Bodor and Montalvo used ultrasound to evaluate the location and depth of the subdeltoid bursa. Their measurements helped establish the anatomical plausibility that a standard vaccination needle could penetrate the deltoid and enter the bursa.
Subsequent authors repeatedly cited their observation that the bursa may lie only approximately 0.8–1.6 cm beneath the skin in some individuals.
Thus, ultrasound initially helped answer:
Could an intramuscular vaccination needle actually reach the structures implicated in SIRVA?
The answer was anatomically yes.
What Can Conventional Shoulder Ultrasound Show?
Ultrasound can readily evaluate structures commonly implicated in SIRVA, including:
subacromial/subdeltoid bursa,
supraspinatus and other rotator cuff tendons,
long-head biceps tendon,
joint fluid,
cortical surfaces,
dynamic shoulder mechanics,
and selected findings associated with adhesive capsulitis.
Published SIRVA cases and series have used ultrasound to identify bursitis, rotator cuff abnormalities, calcific tendinopathy, and other pathology. Our SIRVA evidence database includes ultrasound use across case reports and series involving bursitis, adhesive capsulitis, cuff abnormalities, and image-guided interventions.
But that creates the same problem encountered with MRI:
Finding an abnormality is not the same as establishing SIRVA.
Bursitis and rotator cuff abnormalities occur in patients without vaccine-related shoulder injury.
Historically, Ultrasound Had No Established SIRVA-Specific Finding
This limitation is important.
Our 2026 Clinical Journal of Sport Medicine publication noted that although ultrasound is effective for identifying bursitis, rotator cuff disorders, adhesive capsulitis, and bony abnormalities, the literature supporting ultrasound specifically for the diagnosis of SIRVA remained limited.
In other words, ultrasound could answer:
“What shoulder pathology is present?”
but not necessarily:
“Is this pathology specifically related to vaccine administration?”
That distinction remains important today.
Ultrasound Can Do Something MRI Cannot: Interrogate the Pain Generator
One of ultrasound's potentially important advantages is that the examination can become interactive.
A clinician can:
identify an abnormality,
correlate it with the patient's focal symptoms,
use sonopalpation,
guide a small-volume anesthetic injection precisely into the suspected structure,
and immediately reassess the provocative maneuver.
That creates a different type of information from a static imaging study.
The question changes from:
“Is there an abnormality?”
to:
“Is this particular abnormality actually generating the patient's pain?”
That can be particularly useful in SIRVA because patients frequently have more than one abnormality on imaging.
Bodor, Uribe, and Srikumaran reported five patients with chronic post-vaccination shoulder pain lasting an average of approximately 20 months.
They used ultrasonography, sonopalpation, and ultrasound-guided anesthetic injections to localize the source of symptoms. In all five patients, the distal infraspinatus and/or teres minor tendon insertions and adjacent bone were identified as pain generators.
The investigators subsequently performed ultrasound-guided ultrasonic aspiration and debridement, with substantial improvement in QuickDASH scores.
This work suggested a broader role for ultrasound:
anatomical localization → diagnostic confirmation → targeted intervention.
In 2026, our group reported five patients with persistent SIRVA in whom ultrasound demonstrated a distinct pattern of multiple punctate hyperechoic foci within the rotator cuff tendons.
The abnormalities were described as different from the sonographic appearance typically associated with degenerative tendinopathy or an acute rotator cuff tear.
Importantly, we did not rely on imaging appearance alone.
Each suspected lesion underwent a targeted ultrasound-guided diagnostic anesthetic injection to determine whether the identified region represented the patient's pain generator. We proposed that a particular sonographic pattern, when present in the appropriate clinical context and supported by a targeted diagnostic response, may help identify clinically relevant pathology in selected patients with persistent symptoms.
Does This Mean Ultrasound Can Now Diagnose SIRVA?
No. That would go beyond the evidence.
Our study included only five patients. There was no asymptomatic control group, no comparison group of patients with conventional rotator cuff disease, and no histopathologic confirmation establishing what the punctate abnormalities represented.
The findings require independent replication.
This is an important example of the distinction discussed in our article on whether a new publication changes the standard of care:
A newly described finding can be clinically interesting without becoming an established diagnostic criterion.
At present, there is no validated ultrasound test that independently establishes SIRVA.
Ultrasound May Be Most Useful When MRI Is Nonspecific
MRI remains highly valuable for evaluating the shoulder, particularly when the clinical question involves:
bone marrow,
deep joint pathology,
rotator cuff tearing,
capsular abnormalities,
extensive inflammatory changes,
or alternative diagnoses.
Recent MRI cohorts continue to expand the described spectrum of SIRVA-associated abnormalities.
But MRI abnormalities frequently lack specificity.
The updated systematic review by MacMahon and colleagues emphasizes the broader uncertainty surrounding SIRVA and the limitations of the available evidence.
Ultrasound may add value when the clinical question is more focused:
Which of several abnormalities is actually painful?
This is where sonopalpation and diagnostic injection may be particularly helpful.
Diagnostic Injection Helps Localize Pain—not Establish Causation
This distinction is especially important in a medical-legal setting.
Suppose ultrasound identifies an abnormal supraspinatus region and a targeted anesthetic injection produces substantial temporary pain relief.
That supports:
the identified region is likely contributing to the patient's pain.
It does not independently establish:
vaccination caused that abnormality.
Causation still requires consideration of:
pre-vaccination shoulder status,
timing of symptom onset,
injection location and depth,
anatomical plausibility,
other imaging findings,
alternative diagnoses,
subsequent trauma,
and the overall clinical course.
Ultrasound may strengthen anatomical localization without resolving etiologic causation.
Has Ultrasound Changed Treatment?
Potentially, particularly in selected chronic cases. The Bodor series demonstrated an ultrasound-based pathway from localization through targeted minimally invasive treatment.
Our subsequent case series similarly used ultrasound findings and confirmatory diagnostic injections to select patients for ultrasound-guided tenotomy, vacuum aspiration, and debridement.
This represents an emerging approach rather than established SIRVA treatment.
There are no randomized trials demonstrating that ultrasound-directed intervention is superior to conventional treatment, and the broader SIRVA treatment literature remains dominated by observational studies and case reports. Reviews continue to note the lack of randomized comparative treatment evidence.
MRI and Ultrasound Should Not Be Viewed as Competitors
The most useful framework may be to view them as complementary.
MRI provides comprehensive structural assessment and is particularly useful for deep joint, marrow, capsular, and extensive soft-tissue pathology.
Ultrasound provides high-resolution dynamic assessment of superficial structures and permits immediate sonopalpation and targeted diagnostic procedures.
Neither establishes SIRVA independently. The clinical value comes from matching the imaging modality to the question being asked.
The Bottom Line
Has ultrasound research changed how SIRVA is evaluated?
Historically, ultrasound primarily demonstrated conventional shoulder pathology and helped establish the anatomical plausibility of vaccine over penetration.
More recent work suggests a broader role:
identify pathology
→ correlate the abnormality with symptoms
→ use targeted diagnostic injection to test whether it is a pain generator
→ in selected refractory cases, potentially guide treatment.
But the evidence does not yet support a SIRVA-specific ultrasound diagnostic standard.
For now, the most defensible conclusion is:
Ultrasound may improve anatomical localization and help determine which structure is producing pain in selected patients with suspected SIRVA. Emerging sonographic findings are promising but require validation before they can be considered diagnostic of vaccine-related injury.
That distinction is particularly important in causation analysis: ultrasound can help establish where the pain is coming from; it cannot, by itself, establish why the pathology occurred.
References
Bodor M, Montalvo E. Vaccination-related shoulder dysfunction. Vaccine. 2007;25(4):585-587.
Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA). Vaccine. 2010;28(51):8049-8052.
Cook IF. Subdeltoid/subacromial bursitis associated with influenza vaccination. Hum Vaccin Immunother. 2014;10(3):605-606.
Cantarelli Rodrigues T, Hidalgo PF, Skaf AY, Serfaty A. Subacromial-subdeltoid bursitis following COVID-19 vaccination: a case of shoulder injury related to vaccine administration (SIRVA). Skeletal Radiol. 2021;50(11):2293-2297.
Bodor M, Uribe Y, Srikumaran U. Ultrasonic aspiration for vaccination-related shoulder dysfunction. Heliyon. 2021;7:e08442.
MacMahon A, Nayar SK, Srikumaran U. What do we know about shoulder injury related to vaccine administration? An updated systematic review. Clin Orthop Relat Res. 2022;480(7):1241-1250.
Pettyjohn EW, Clugston JR, Zaremski JL. Shoulder injury related to vaccine administration and a growing challenge: a focused review. Curr Sports Med Rep. 2022;21(3):78-83.
Petrakis N, Addison M, Penak B, et al. Shoulder injury following COVID-19 vaccine administration: a case series and proposed diagnostic algorithm. Expert Rev Vaccines. 2023;22(1):299-306.
Fortier LM, Smith KL, Ina JG, et al. Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review. J Shoulder Elbow Surg. 2024;33(1):202-209.
Sussman WI, Davitt K, Mitchell K, Sussman J, Latzka E. Sonographic features of Shoulder Injury Related to Vaccine Administration: a case series. Clin J Sport Med. 2026.
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