What Does SIRVA Look Like on MRI?
One of the most common questions in a suspected Shoulder Injury Related to Vaccine Administration (SIRVA) case is:
“What should the MRI show? The answer is important:
SIRVA does not have a single pathognomonic MRI appearance.
MRI can demonstrate abnormalities reported in SIRVA, but it generally cannot determine by itself whether vaccination caused them.
That distinction becomes especially important when an MRI shows common findings such as rotator cuff tendinopathy or a partial-thickness tear.
What MRI Findings Have Been Reported?
Across the SIRVA literature, MRI abnormalities have included:
subacromial/subdeltoid bursitis,
rotator cuff tendinopathy,
partial- and full-thickness rotator cuff tears,
biceps tenosynovitis,
adhesive capsulitis,
glenohumeral synovitis,
joint effusion,
muscle edema or myositis,
bone marrow edema,
cortical or greater tuberosity erosions,
and, less commonly, other osseous abnormalities.
This heterogeneity is consistent with SIRVA being an umbrella clinical syndrome involving different anatomical structures, rather than one discrete MRI diagnosis.
Hesse and colleagues' analysis of 476 conceded SIRVA claims found that common MRI findings included tendinopathy, rotator cuff tears, and bursitis, with bone edema and necrosis occurring less frequently. Importantly, the authors cautioned that these findings should not be equated with prima facie evidence of vaccine causation.
Bursitis Is One of the Classic Findings
Subacromial/subdeltoid bursitis is among the findings most closely associated with the traditional SIRVA mechanism.
The proposed explanation is anatomically intuitive: a vaccine intended for the deltoid is inadvertently deposited into or near the bursa, producing a local inflammatory response.
MRI may demonstrate:
bursal distention, fluid, synovial thickening, or surrounding inflammatory change.
However, bursitis is not specific to vaccination. It occurs with rotator cuff disease, impingement, trauma, inflammatory disorders, and sometimes without substantial symptoms.
Therefore:
Bursitis may be compatible with SIRVA, but bursitis does not equal SIRVA.
Timing May Change What the MRI Shows
One of the more interesting findings from our review of the SIRVA imaging literature is that MRI appearance may depend on when imaging is performed.
The chronic MRI study by Donners and colleagues provides an important example.
Their median interval between vaccination and MRI was approximately 35 weeks. In that chronic cohort, subdeltoid bursitis was found in only one patient. The investigators contrasted this with earlier imaging, where bursitis appeared more frequently, and proposed that bursitis may be more representative of an acute inflammatory phase.
This means an MRI obtained:
three days after vaccination may reasonably look different from one obtained at eight months later.
That is important when comparing individual cases with published studies.
What Does Chronic SIRVA Look Like?
Donners and colleagues specifically studied chronic-stage SIRVA using contrast-enhanced MRI.
Their most prominent findings included:
Greater tuberosity erosions — 89%
Infraspinatus tendinitis — 78%
along with frequent:
capsulitis, synovitis, and bone marrow edema.
The authors concluded that greater tuberosity erosions, infraspinatus tendinitis, capsulitis, synovitis, and marrow edema represented common findings in their chronic cohort.
Bone Abnormalities May Develop Over Time
The osseous findings are particularly interesting. Donners reported greater tuberosity erosions in most of their chronic cases, but their imaging was obtained substantially later than in earlier studies.
They cited a particularly informative case in which:
MRI at two days showed no erosion, but follow-up MRI at three months demonstrated a greater tuberosity erosion.
That observation raises the possibility that at least some MRI abnormalities may evolve rather than appear immediately.
It also means that absence of an erosion on an early MRI would not necessarily contradict its appearance later. However, the biological mechanism underlying these changes remains incompletely established.
Serial MRI Can Be Particularly Informative
Serial imaging is uncommon in the SIRVA literature, but when available it can provide useful information about temporal evolution.
In the Donners cohort, one patient underwent serial contrast-enhanced MRI over more than two years and demonstrated progressive enlargement of a greater tuberosity erosion.
A changing abnormality may provide different causation information than a stable chronic degenerative finding discovered after vaccination.
It still does not establish causation independently, but longitudinal imaging can help address the question:
Is this pathology static, resolving, or evolving?
What About Rotator Cuff Tears?
This requires particular caution. Rotator cuff tears are repeatedly reported in SIRVA MRI studies, but they are also common in adults without vaccine-related shoulder injury.
Hesse specifically warned against assuming that rotator cuff abnormalities seen after vaccination were necessarily caused by vaccination because similar abnormalities occur commonly in middle-aged and older adults.
Thus, an MRI showing:
“partial-thickness supraspinatus tear” does not answer:
“Did the vaccination cause this patient's shoulder symptoms?”
That requires a separate analysis.
MRI Abnormality and Pain Generator Are Not the Same Thing
An MRI may identify several abnormalities simultaneously:
supraspinatus tendinopathy,
partial tearing,
AC joint arthritis,
labral degeneration,
bursitis,
and glenohumeral osteoarthritis.
Which one is causing the patient's new symptoms? MRI often cannot answer that question by itself.
This is one reason musculoskeletal ultrasound and targeted diagnostic injections may sometimes complement MRI: they can help determine whether a specific anatomical region reproduces or contributes to the patient's symptoms.
The distinction is:
MRI → identifies structural abnormalities while
clinical correlation → determines their significance.
Can MRI Distinguish Preexisting Disease From SIRVA?
Sometimes it provides clues, but often not definitively.
Degenerative tendinopathy, chronic cuff tearing, muscle atrophy, osteoarthritis, and degenerative labral abnormalities may suggest longstanding disease.
Acute edema, substantial new bursal fluid, synovitis, or evolving marrow abnormalities may suggest a more active process.
But MRI generally cannot precisely date many common shoulder abnormalities.
This is why pre-vaccination imaging, when available, can be exceptionally valuable.
Without it, one must distinguish:
preexisting structural abnormality from
preexisting symptomatic disease.
Those are not the same thing.
More recently, Obeidat and colleagues evaluated MRI findings in 38 shoulders from 35 patients following COVID-19 vaccination. Their study reported a broad spectrum of abnormalities, with subacromial/subdeltoid bursitis particularly prominent and rotator cuff abnormalities also common. The authors interpreted MRI as useful for identifying the range of pathology associated with suspected SIRVA while acknowledging important study limitations.
Does Contrast Matter?
Potentially. The Donners study found that inflammatory findings such as:
capsulitis, synovitis, and tendinitis were better appreciated on contrast-enhanced MRI than on fluid-sensitive sequences alone.
Based on their findings, the authors recommended intravenous contrast when evaluating suspected chronic SIRVA to improve detection of inflammatory pathology.
That is an interesting research recommendation, but it should not be interpreted as establishing that every suspected SIRVA case requires contrast-enhanced MRI.
The evidence comes from a small retrospective cohort and requires broader validation.
Can MRI Prove SIRVA?
No. This is probably the most important point in the article.
Even the Donners study, which identified a distinctive cluster of chronic inflammatory findings, emphasized that erosions, tendinitis, capsulitis, synovitis, and bone marrow edema are nonspecific indicators of joint inflammation.
The authors also acknowledged that they did not have baseline MRI examinations at symptom onset and therefore could not unequivocally prove that the abnormalities represented SIRVA manifestations.
That is an appropriate limitation.
Can a Normal MRI Exclude SIRVA?
Not necessarily. SIRVA remains primarily a clinical diagnosis supported by imaging, rather than an MRI-defined disease.
The imaging appearance may depend on:
which structure was affected,
when imaging was obtained,
whether contrast was used,
whether pathology has resolved or evolved,
and which sequences were performed.
Plain radiographs may also be normal despite persistent symptoms. Wong and colleagues similarly emphasized that MRI findings are sensitive for shoulder pathology but generally nonspecific.
Therefore, neither:
“abnormal MRI = SIRVA”, nor
“normal MRI = no SIRVA”
is scientifically defensible.
MRI Is Most Useful When It Fits the Clinical Story
MRI becomes more persuasive when several elements converge:
previously asymptomatic shoulder
appropriate temporal relationship to vaccination
anatomically plausible injection mechanism
MRI pathology corresponding to the symptomatic region
findings compatible with the timing of imaging
absence of a better alternative explanation.
The MRI is then one component of a coherent causal analysis.
Why This Matters in Medical-Legal Review
An MRI report may sound compelling:
“Rotator cuff tear, bursitis, and labral degeneration.”
But those words alone do not establish causation. The medical-legal questions are more specific:
Was the abnormality likely present before vaccination?
Does it look inflammatory, degenerative, traumatic, or nonspecific?
Does its location make sense relative to the proposed injection?
When was the MRI performed?
Does the imaging correlate with the patient's symptoms and examination?
Did the abnormality evolve on serial imaging?
Is there a competing diagnosis that better explains it?
These questions turn an MRI from a list of abnormalities into clinically meaningful evidence.
The Bottom Line
So, what does SIRVA look like on MRI? There is no single answer.
Published SIRVA MRI findings span:
bursitis → tendinitis → rotator cuff abnormalities → capsulitis → synovitis → marrow edema → osseous erosions.
The pattern may also evolve with time. Early inflammatory presentations may show more bursal pathology, while chronic studies have identified tendon, capsular, synovial, marrow, and erosive abnormalities.
The most defensible interpretation is:
MRI can demonstrate pathology compatible with SIRVA and, in the appropriate clinical setting, may strengthen anatomical and biological plausibility. But no currently established MRI finding independently diagnoses SIRVA or proves vaccine causation.
The question should therefore not be:
“Does this MRI show SIRVA?”
but:
“Do the MRI findings, their location and apparent chronicity, and the timing of the study fit the patient's clinical history and proposed mechanism better than reasonable alternative explanations?”
References
Bodor M, Montalvo E. Vaccination-related shoulder dysfunction. Vaccine. 2007;25(4):585-587. doi:10.1016/j.vaccine.2006.08.034.
Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA). Vaccine. 2010;28(51):8049-8052. doi:10.1016/j.vaccine.2010.10.005.
Okur G, Chaney KA, Lomasney LM. Magnetic resonance imaging of abnormal shoulder pain following influenza vaccination. Skeletal Radiol. 2014;43:1325-1331.
Hesse EM, Atanasoff S, Hibbs BF, et al. Shoulder Injury Related to Vaccine Administration (SIRVA): petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016. Vaccine. 2020;38(5):1076-1083. doi:10.1016/j.vaccine.2019.11.032. The authors specifically cautioned against interpreting common MRI abnormalities as prima facie evidence of vaccine causation.
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.
Donners R, Gehweiler JE, Kovacs BK, et al. Chronic stage magnetic resonance imaging findings in patients with shoulder injury related to vaccine administration (SIRVA). Skeletal Radiol. 2023;52:1695-1701. doi:10.1007/s00256-023-04334-3. The study identified greater tuberosity erosions, infraspinatus tendinitis, capsulitis, synovitis, and bone marrow edema as prominent chronic findings.
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. doi:10.1097/CORR.0000000000002181.
Slette E, Rohrback M, Ring D. Persistent shoulder pain after vaccine administration is associated with common incidental pathology: a systematic review. Clin Orthop Relat Res. 2022;480(7):1251-1258. doi:10.1097/CORR.0000000000002191.
Wong W, et al. Arthroscopic surgical management of shoulder secondary to shoulder injury related to vaccine administration (SIRVA): a case report. The authors emphasize that MRI findings may include bursitis, tendinitis, tenosynovitis, and rotator cuff tearing but remain generally nonspecific.
Obeidat N, Khasawneh R, Alrawashdeh A, et al. Shoulder Injury Related to Vaccine Administration (SIRVA) following COVID-19 vaccination: correlating MRI findings with patient demographics. Tomography. 2025;11(5):53.
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