From the Guidelines
Contrast is recommended when assessing for tenosynovitis on MRI, as it improves detection according to the most recent guidelines. The inclusion of postcontrast images to MRI of the wrist has been shown to enhance the detection of tenosynovitis 1. While non-contrast MRI sequences can be sufficient in some cases, the use of intravenous contrast can provide additional value in cases where there is diagnostic uncertainty or when more detailed assessment is needed. Key benefits of contrast enhancement include differentiating active synovial inflammation from simple fluid accumulation and better delineating synovial proliferation. This is particularly useful in complex cases such as rheumatoid arthritis, infection, or when evaluating for complications.
Some of the key points to consider when deciding on the use of contrast in MRI for tenosynovitis include:
- The clinical scenario and suspected underlying pathology
- The specific anatomic region being evaluated
- The need for detailed assessment of disease activity, especially in inflammatory arthritides like rheumatoid arthritis
- The potential for contrast to improve the detection of tenosynovitis, as indicated by recent guidelines 1
Given the most recent evidence, the use of contrast in MRI for assessing tenosynovitis is supported by high-quality studies, such as the 2023 update on ACR Appropriateness Criteria for chronic hand and wrist pain 1, which emphasizes the role of postcontrast images in improving detection. Although older studies like the 2018 ACR Appropriateness Criteria for chronic wrist pain also discuss the utility of contrast in certain scenarios 1, the most recent guideline provides the strongest and most current recommendation.
From the Research
Assessment of Tenosynovitis on MRI
- The use of contrast in MRI assessments for tenosynovitis has been evaluated in several studies 2, 3, 4, 5, 6.
- A study from 2006 found that enhanced MR imaging of the hand and wrist is a superior technique for detection of tenosynovitis, with higher contrast-enhancement scores and inflammation noted in the hand flexor than in the extensor tendons 2.
- Another study from 2009 noted that MRI scanning is the current gold standard modality for imaging synovitis and tenosynovitis in patients with inflammatory arthritis, and that inflamed synovial membrane within the joints and investing tendon sheaths appears thickened on T1-weighted sequences and enhances postcontrast 3.
- However, a study from 1997 suggested that routine use of gadolinium is not warranted, and that it should be reserved for clinically suspected infection in or around a joint, and in cases refractory to medical or surgical treatment due to possible abscess formation 4.
- More recent studies have continued to evaluate the use of MRI in detecting tenosynovitis, including a 2015 study that found MRI-detected tenosynovitis is commonly seen in early arthritis, and that the flexor tendons at MCP5, the extensor tendons at MCP2 and MCP4, and the first extensor compartment of the wrist are more often affected in RA patients 5.
- A 2019 study compared the use of musculoskeletal ultrasound and MRI in identifying synovitis and tenosynovitis, and found that while MRI is more sensitive, ultrasound is less sensitive but results in only few non-specific findings 6.
Key Findings
- Enhanced MR imaging is superior for detection of tenosynovitis 2.
- MRI scanning is the gold standard modality for imaging synovitis and tenosynovitis in patients with inflammatory arthritis 3.
- Routine use of gadolinium may not be necessary, but it can be useful in certain cases 4.
- MRI-detected tenosynovitis is common in early arthritis, and certain tendons are more often affected in RA patients 5.
- Ultrasound is less sensitive than MRI for detecting synovitis and tenosynovitis, but results in few non-specific findings 6.