Technically Speaking: Let’s Get It Right! How to Avoid Shoulder Injury with Deltoid Intramuscular Injections

During influenza vaccination season, and at all times of the year, it is critically important that clinic staff who administer vaccines avoid injury to patients’ shoulders by being knowledgeable about how to properly administer intramuscular injections in the deltoid muscle.

At the October 2017 Advisory Committee on Immunization Practices meeting, a presentation titled “Reports of Shoulder Dysfunction Following Inactivated Influenza Vaccine in the Vaccine Adverse Event Reporting System (VAERS), 2010–2016”, included the following background information about shoulder injury related to vaccine administration (SIRVA):

• Definition: SIRVA is caused by injury to the musculoskeletal structures of the shoulder (e.g., tendons, ligaments, bursae, etc.)
• It manifests itself as shoulder pain and limited range of motion occurring after a patient receives a vaccine intended for intramuscular administration.
• These symptoms are thought to occur as a result of unintended injection of vaccine antigen or trauma from the needle going into and around the underlying bursa of the shoulder, resulting in an inflammatory reaction.

SIRVA may result in patients having chronic shoulder pain and limited range of motion, and require ongoing medical intervention.

To avoid SIRVA, make sure clinic staff who administer vaccines recognize the anatomic landmarks for identifying the deltoid muscle and use proper intramuscular administration technique.

Helpful resources to assist with staff education

IAC resources

• How to administer intramuscular and subcutaneous vaccine injections to adults — This one-page educational tool includes diagrams and descriptions of boney landmarks and provides practical, easy-to-understand instructions for administering injections.
• How to administer intramuscular and subcutaneous vaccine injections — Covers infants, children, teens and adults.
• Administering vaccines: Dose, route, site, and needle size.
• Administering vaccines to adults: Dose, route, site, and needle size.
• Skills checklist for vaccine administration.
• Administering vaccines: Handouts webpage — With many additional free, downloadable, ready-to-print materials (all CDC-reviewed).
• DVD – Immunization techniques: Best practices for infants, children and adults — Updated in 2010 by the California Department of Public Health, this 25-minute DVD helps ensure that staff administer vaccines correctly.

CDC resources

• Vaccine administration e-learn — A self-paced vaccine administration course that provides comprehensive training using videos, job aids, and other resources.
• Vaccine administration resource library — Contains more than a dozen brief vaccine administration and web-based trainings (including Intramuscular Injection Sites listed below).
• Intramuscular injection sites video — Covers vaccinations for children and adults.
• Infographic on vaccine administration technique for adults.
• Vaccine administration web section.
• General best practice guidelines for immunization: Best practices guidance of ACIP. See the special Vaccine Administration section on in web text format.) A version in PDF formatted is also available.
• Epidemiology and Prevention of Vaccine-Preventable Diseases ("The Pink Book") has a chapter on vaccine administration.