TRAHAN v. SECRETARY OF HEALTH AND HUMAN SERVICES

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-1791V
CHRISTIE TRAHAN,
Petitioner,
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Chief Special Master Corcoran
Filed: December 9, 2025
Daniel Alholm, Alholm Law, P.C., Chicago, IL, for Petitioner.
Michael Bliley, U.S. Department of Justice, Washington, DC, for Respondent.
RULING ON ENTITLEMENT1
On October 12, 2023, Christie Trahan filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”), later amending her claim (ECF No. 6). Petitioner alleges that she suffered
a shoulder injury related to vaccine administration (“SIRVA”) following an influenza
vaccine received on December 20, 2021. Amended Petition at 1. The case was assigned
to the Special Processing Unit of the Office of Special Masters.
For the reasons discussed below, I find that Petitioner more likely than not suffered
the residual effects of her alleged vaccine-related injury for more than six months, and
1 Because this Ruling contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling will be available to anyone with access to the internet. In accordance
with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I agree that
the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2018).
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that she has satisfied all of the requirements for a Table SIRVA claim. She is therefore
entitled to compensation under the Vaccine Act.
I. 	Relevant Procedural History
On July 1, 2024, Respondent filed his Rule 4(c) Report arguing in part that the
Vaccine Act’s “severity requirement” was not met. Rule 4(c) Report at 6. Petitioner
subsequently filed a Motion for Ruling on the Record (“Mot.”) on September 9, 2024. ECF
No. 23. Respondent filed a response (“Resp.”) on November 8, 2024, and Petitioner filed
a reply (“Repl.”) on November 15, 2024. ECF No. 24-25. The matter is now ripe for
adjudication.
II. 	Relevant Facts
A. Medical Records
Petitioner received a flu vaccine in her left deltoid on December 20, 2021. Ex. 3 at
3. Approximately three weeks later (January 13, 2022), Petitioner sought treatment from
an orthopedist. Ex. 6 at 59. She reported left shoulder pain “after being given a flu shot
on 12/20/2021.” Id. On exam, Petitioner had tenderness and crepitus, decreased range
of motion due to pain, and positive impingement signs. Id. at 60. She was diagnosed with
subacromial bursitis and referred to occupational therapy. Id.
The following day, Petitioner submitted a report to the Vaccine Adverse Event
Reporting System. Ex. 5. She reported the date of onset as “12/21/2021,” the day after
vaccination. Id. at 4.
Ms. Trahan began occupational therapy on January 17, 2022. Ex. 6 at 40. She
complained of “post-injection bursitis” that caused limited use of her left shoulder along
with weakness and stiffness. Id. The therapist noted that Petitioner “reported feeling
immediate, sharp pain to L shoulder at time of injection.” Id. at 41. On exam, she displayed
“concerns for development of secondary adhesive capsulitis.” Id. Treatment was planned
for eight visits over four weeks. Id. She returned for a second treatment on January 26,
2022. Ex. 8 at 330. At that visit, she reported that “starting therapy really helped [her] arm
move and feel better.” Id.
There is a subsequent and lengthy treatment gap of over ten months. In that
interval, Petitioner obtained an ob/gyn examination on August 15, 2022. Ex. 9 at 25. She
also sought urgent care in September 2022 for a Covid-19 infection (Ex. 13 at 1) and later
that same month was diagnosed with bronchitis. Ex. 11 at 7. She also received another
flu vaccine in October 2022 (Ex. 12 at 8), and saw her primary care provider (“PCP”) for
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high cholesterol that was discovered in the bloodwork ordered by her ob/gyn. Id. at 54.
None of the records from these encounters include reference to shoulder pain.
Petitioner returned to her orthopedist for shoudler-specific treatment on December
15, 2022. Ex. 6 at 55. She was seen for a “follow-up evaluation” and reported that her
“symptoms [had] been present for approximately 1 year.” Id. Her exam included full range
of motion with pain, crepitus, tenderness, and positive impingement testing. Id. at 56. She
was diagnosed with bursitis and impingement syndrome. Id. An MRI revealed mild
superior spurring of the acromioclavicular joint, mild bursitis, and rotator cuff tendinosis.
Id. at 28.
Petitioner returned to her orthopedist on January 5, 2023 to review the MRI results.
Ex. 6 at 52. She was given a cortisone injection and a home exercise program. Id. at 53.
She subsequently continued to treat her left shoulder symptoms through the remainder
of 2023, with physical therapy and later surgery. See Ex. 6, Ex. 8.
B. Relevant Witness Testimony
Petitioner filed a declaration on October 24, 2023, and a supplemental declaration
on September 9, 2024. Ex. 4, 14. She states that she “woke up with extreme pain in [her]
left shoulder” the morning after her vaccination. Ex. 14 at ¶1. At the time of her
vaccination, she had a high deductible insurance plan, requiring her to pay up to
$7,070.00 in medical expenses per year. Ex. 4 at ¶4; Ex. 14 at ¶3. She paid out-of-pocket
for the initial treatment for her left shoudler pain, but then determined that it was too
expensive to continue. Id. She explained that her husband’s hours had been reduced due
during the Pandemic, causing the family to go into debt. Id. She felt that her “only option
was to try to heal [herself] with a physical therapy program [she] received from [her]
doctors, rest, exercises and hot and cold compresses.” Id. at ¶2. As a result of the
associated costs, Petitioner would “only go to the doctor when absolutely necessary.” Id.
at ¶3.
In 	May 	2022, 	Petitioner’s 	husband 	obtained 	a 	new 	job 	which 	provided
comprehensive medical insurance “for the first time ever.” Ex. 14 at ¶3. Petitioner explains
that once she had health insurance, she tried to be more “proactive” about her health,
starting with screenings for “any serious health issues that could be life threatening.” Id.
at ¶6. She noted that “it had been over a decade since [she] had a routine comprehensive
medical exam,” and that “although [her] shoulder hurt, [she] knew [she] wasn’t going to
die from it.” Id. After addressing her overall health, including seeing an ob/gyn and PCP
for high cholesterol, Petitioner returned to treatment for her left shoulder. Id. at ¶5-7.
Nicholas Trahan, Petitioner’s husband, also filed a declaration in support of
Petitioner’s claim. See Ex. 15. He stated that his employer at the time of Petitioner’s
vaccination did not offer medical insurance, so they had only a high-deductible plan to
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cover emergencies. Id. at ¶4. He noted that they “rarely went to the doctor.” Id. During the
Covid-19 Pandemic, Mr. Trahan’s hours were cut, which led to the family “having to take
on debt.” Id. at ¶5. He stated that Petitioner did not suffer any “new or additional left
shoulder injuries” during her gap in formal treatment. Id. at ¶7.3
III. 	Applicable Legal Standards
Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove by a
preponderance of the evidence the matters required in the petition by Vaccine Act Section
11(c)(1). The Vaccine Act also requires that a petitioner demonstrate that “residual effects
or complications” of a vaccine-related injury continued for more than six months. Vaccine
Act §11(c)(1)(D)(i). A petitioner cannot establish the length or ongoing nature of an injury
merely through self-assertion unsubstantiated by medical records or medical opinion.
§13(a)(1)(A). “[T]he fact that a petitioner has been discharged from medical care does not
necessarily indicate that there are no remaining or residual effects from her alleged
injury.” Morine v. Sec’y of Health & Human Servs., No. 17-1013V, 2019 WL 978825, at
*4 (Fed. Cl. Spec. Mstr. Jan. 23, 2019); see also Herren v. Sec’y of Health & Human
Servs., No. 13-1000V, 2014 WL 3889070, at *3 (Fed. Cl. Spec. Mstr. July 18, 2014).
Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Section 11(c)(1).
A special master must consider, but is not bound by, any diagnosis, conclusion, judgment,
test result, report, or summary concerning the nature, causation, and aggravation of
petitioner’s injury or illness that is contained in a medical record. Section 13(b)(1).
“Medical records, in general, warrant consideration as trustworthy evidence. The records
contain information supplied to or by health professionals to facilitate diagnosis and
treatment of medical conditions. With proper treatment hanging in the balance, accuracy
has an extra premium. These records are also generally contemporaneous to the medical
events.” Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir.
1993).
Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this rule
does not always apply. In Lowrie, the special master wrote that “written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Lowrie, at *19. And the Federal Circuit recently “reject[ed] as
incorrect the presumption that medical records are accurate and complete as to all the
3 Mr. Trahan’s Affidavit contains paragraphs numbered 5, 6, and 5. Therefore, the second paragraph labeled
“5” will be noted herein as “7.” See Ex. 15 at 3.
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patient’s physical conditions.” Kirby v. Sec’y of Health & Human Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).
The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Human Servs., 42 Fed.
Cl. 	381, 	391 	(1998). 	The 	Court 	later 	outlined 	four 	possible 	explanations 	for
inconsistencies 	between 	contemporaneously 	created 	medical 	records 	and 	later
testimony: (1) a person’s failure to recount to the medical professional everything that
happened during the relevant time period; (2) the medical professional’s failure to
document everything reported to her or him; (3) a person’s faulty recollection of the events
when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did
not exist. La Londe v. Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013),
aff’d, 746 F.3d 1335 (Fed. Cir. 2014).
The Court has also said that medical records may be outweighed by testimony that
is given later in time that is “consistent, clear, cogent, and compelling.” Camery, 42 Fed.
Cl. at 391 (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-2808, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998). The credibility of the individual offering
such testimony must also be determined. Andreu v. Sec’y of Health & Human Servs., 569
F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Human Servs., 991 F.2d
1570, 1575 (Fed. Cir. 1993).
The special master is obligated to fully consider and compare the medical records,
testimony, and all other “relevant and reliable evidence contained in the record.” La
Londe, 110 Fed. Cl. at 204 (citing Section 12(d)(3); Vaccine Rule 8); see also Burns v.
Sec’y of Health & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within
the special master's discretion to determine whether to afford greater weight to medical
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).
IV. 	Findings of Fact - Severity
To satisfy the statutory severity requirement, Petitioner must demonstrate that her
symptoms more likely than not continued until at least June 21, 2022 – six months after
the onset of her pain on December 21, 2021 (the day after vaccination). See Ex. 14 at ¶1.
The record establishes (and the parties agree) that Petitioner treated her left shoulder
pain with one orthopedist visit and two physical therapy appointments through January
26, 2022, just over one month after her vaccination. Petitioner then did not seek shoulder-
related care again for almost 11 months. Respondent contends that Petitioner has not
provided preponderant evidence that her vaccine-related symptoms persisted for at least
six months because she had “multiple intervening medical appointments where she did
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not report any left shoulder pain or limitations.” Resp. at 7-9. Respondent further contends
that Petitioner’s intervening medical appointments indicate that she did not have financial
constraints that limited her ability to seek care for her shoulder. Id. at 9.
When Petitioner first began physical therapy, treatment was planned for eight
sessions over four weeks. Ex. 6 at 40. Although she did not complete the planned therapy,
Petitioner has provided a credible explanation for why she did not seek further treatment
at that time. Petitioner explains that her high-deductible insurance plan (which required
substantial out-of-pocket payments) made her highly reluctant to seek care. Ex. 4 at ¶4;
Ex. 14 at ¶2; See also Ex. 15 at ¶4-5. Petitioner also states that she tried to self-treat her
left shoulder pain with exercises, rest, heat and cold, and that she hoped it would resolve
on its own. Ex. 4 at ¶4; Ex. 14 at ¶2.
When Petitioner returned to treatment after the gap, she was seen for a “follow-up
evaluation,” and reported that her “sytmpoms [had] beem present for approximately 1
year.” Ex. 6 at 55. She was diagnosed with bursitis (the same diagnosis as her initial visit
soon after vaccination) and impingement syndrome. Id. at 56. In addition, at the time of
Petitioner’s last physical therapy treatment on January 26, 2022, she had not met any of
her therapy goals and treatment was planned into the future. Ex. 8 at 330. Although
Respondent 	notes 	that 	Petitioner 	reported 	improvement 	during 	that 	early 	2022
appointment, there is no evidence that Petitioner’s shoulder pain had resolved at that
time, or any time prior to her follow-up treatment in December 2022. Further, Respondent
does not point to any evidence in the record of an alternative cause for her symptoms
since the flu shot.
Respondent highlights the fact that Petitioner had several medical visits during the
intervening period during which she did not complain of shoulder pain. Resp. at 7. But
these medical visits were not necessarily occasions on which a person would have been
expected to report her shoulder pain. See Ex. 9 at 25 (ob/gyn exam); Ex. 11 at 7 (urgent
care visit for bronchitis); Ex 12 at 8 (vaccinations, without any appointment record); Ex.
13 at 1 (urgent care visit for Covid-19 infection). Petitioner also saw a new PCP on
October 31, 2022 for high cholesterol that was found during bloodwork done by her
ob/gyn. Ex. 12 at 54. But Petitioner maintains that because she had already seen an
orthopedist, she did not discuss her shoulder pain with the PCP. Ex. 14 at ¶5. Petitioner
explained why she sought treatment in this manner – she was attempting to catch up on
routine medical care and 	screenings that she was unable to do prior 	to having
comprehensive insurance before addressing her ongoing shoulder pain because she
“knew [she] wasn’t going to die” from her shoulder pain. Id. at ¶6. She explained that once
she had “addressed her overall health,” she returned to treatment. Id. at ¶7.
Respondent argues that this case is analogous to Black v. Sec’y of Health &
Human Servs, No. 21-0009V, 2023 WL 4446500 (Fed. Cl. Spec. Mstr. May 22, 2023) in
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which there was a gap in treatment for more than 17 months. Resp. at 7-8. But Black is
distinguishable. 	That claimant 	failed 	to 	provide 	any evidence, other 	than 	witness
statements, to support the severity requirement. See Black, 2023 WL 4446500, at *5. He
argued that he performed a home exercise plan, but without evidence of any prior formal
physical therapy treatment, and also sought treatment after the gap only after Respondent
raised severity as an issue in the case, and did not continue treating thereafter. Id. Here,
Petitioner 	received 	early 	treatment, 	with 	documented 	shoulder 	findings 	and
recommendations for further treatment; has provided a credible explanation for the gap
in treatment; and continued to treat after the gap, including surgically.
The balance of evidence thus supports severity – although only slightly. The length of
the gap is very troubling, especially since Petitioner could have returned to the orthopedist
during this timeframe (given her willingness to seek other treatment in the interval). Her
financial concerns are valid, but since it appears she had insurance coverage as of May
or June 2022, her failure to seek treatment again is problematic. Given these facts,
Petitioner should expect not only to receive a very modest pain and suffering award, but
should calibrate her damages demand (which includes later shoulder surgery) in light of
the fact that the long treatment gap allows for the possibility of injury exacerbation by
other factors – and this is so even if no other intervening explanatory event can be
identified. While SIRVAs involving surgery routinely result in pain and suffering awards in
excess of $100,000.00, no comparable award will be permitted in this case.
V. 	Ruling on Entitlement
A. 	Requirements for Table SIRVA
Respondent has not disputed Petitioner’s proof on any of the QAI requirements for
a Table SIRVA and there is no evidence to the contrary. Resp. at 5-9. Therefore, I find
that Petitioner has provided preponderant evidence to establish that she suffered a Table
SIRVA injury.
B. 	Additional Requirements for Entitlement
Because Petitioner has satisfied the requirements of a Table SIRVA, she need not
prove causation. Section 11(c)(1)(C). However, she must satisfy the other requirements
of Section 11(c) regarding the vaccination received, the duration and severity of injury,
and the lack of other award or settlement. Section 11(c)(A), (B), and (D).
The vaccine record shows that Petitioner received a flu vaccine in her left arm on
December 20, 2021. Ex. 3 at 3; Section 11(c)(1)(A) (requiring receipt of a covered
vaccine). Additionally, Petitioner has stated that she has not filed any civil action or
received any compensation for her vaccine-related injury, and there is no evidence to the
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contrary. Ex. 4 at ¶5; Section 11(c)(1)(E) (lack of prior civil award). And as noted above,
I have found that severity has been established. See Section 11(c)(1)(D)(i) (statutory six-
month requirement). Therefore, Petitioner has satisfied all requirements for entitlement
under the Vaccine Act.
Conclusion
Based on the entire record in this case, I find that Petitioner has provided
preponderant evidence satisfying all requirements for a Table SIRVA. Petitioner is
entitled to compensation in this case. A separate damages order will be issued.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
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