Is contrast required for Magnetic Resonance Imaging (MRI) for shoulder pain?

From the Guidelines

MRI for shoulder pain typically does not require contrast, as evidenced by the American College of Radiology's appropriateness criteria for shoulder pain-traumatic, which recommends MRI of the shoulder without IV contrast as the most appropriate study in the setting of nonlocalized shoulder pain and negative radiographs 1.

Key Points to Consider

• The use of non-contrast MRI is preferred for evaluating common shoulder problems such as rotator cuff tears, tendinitis, labral tears, and arthritis.
• Contrast agents are typically reserved for specific situations, including infection, inflammatory conditions, certain tumors, or post-surgical evaluations where scar tissue needs to be distinguished from recurrent tears.
• The standard shoulder MRI protocol includes multiple imaging sequences that provide excellent visualization of soft tissues, bone marrow, and joint structures without the need for contrast in most cases.
• The American College of Radiology's guidelines support the use of non-contrast MRI as an initial study for shoulder pain, highlighting its appropriateness and safety 1.

Clinical Decision Making

When deciding whether to use contrast in MRI for shoulder pain, clinicians should consider the patient's specific symptoms, medical history, and suspected condition.

• In cases where the diagnosis is unclear or the patient has a complex medical history, contrast may be necessary to provide additional diagnostic information.
• However, for most patients with shoulder pain, a non-contrast MRI is sufficient and preferred due to the lower risk of adverse reactions and concerns about gadolinium retention in the body.
• The guidelines from the American College of Radiology 1 provide a framework for clinicians to make informed decisions about the use of contrast in MRI for shoulder pain, prioritizing patient safety and diagnostic accuracy.

From the Research

MRI for Shoulder Pain

• The use of MRI for evaluating shoulder pain is essential due to its high resolution and sensitivity in depicting soft tissues 2.
• MRI is the most accurate imaging modality for evaluating shoulder pathology, allowing visualization of the soft tissues that are often the source of pain 3.

Use of Contrast in MRI

• MRI with or without intra-articular contrast can be used to evaluate shoulder pathology 3.
• A study comparing noncontrast MRI and MR arthrography found that indirect magnetic resonance arthrography may facilitate more accurate diagnosis and grading of subscapularis tendon tears compared with noncontrast magnetic resonance imaging 4.
• However, another study found that MRI results in identifying rotator cuff pathologies are comparable with arthroscopy, without mentioning the need for contrast 5.

Diagnostic Accuracy of MRI

• MRI was found to be 92.85% sensitive and 98.8% specific in detecting rotator cuff tears 5.
• Shoulder MRI demonstrated a higher agreement with arthroscopy than clinical results for subscapularis, supraspinatus, infraspinatus, teres, and biceps tendon appearance 5.
• The diagnostic performance of MRI and ultrasound as first-line imaging for rotator cuff injuries is evolving, with both modalities being accurate for identifying rotator cuff tears 6.