MRI of the Hips: Contrast Protocol Recommendations
For most hip MRI indications, order MRI without IV contrast—this is the appropriate first-line protocol for evaluating soft tissue pathology, infection, post-arthroplasty complications, and most musculoskeletal conditions. 1, 2
Clinical Decision Algorithm
Order MRI WITHOUT IV Contrast for:
- Extra-articular soft tissue abnormalities (tendonitis, bursitis, muscle pathology) - rated 9/9 appropriateness 1, 2
- Post-arthroplasty evaluation including suspected infection, adverse reaction to metal debris, abductor injury, or trochanteric bursitis 1
- Occult fracture detection after negative radiographs in traumatic cases 1
- Screening for significant hip pathology when radiographs are negative, equivocal, or nondiagnostic 3, 2
- Bone and soft tissue tumor evaluation (contrast reserved for complex cases) 4
- Routine sports injuries and most musculoskeletal indications 4
Order MR Arthrography (Intra-articular Contrast) for:
- Suspected labral tears with or without femoroacetabular impingement - rated 9/9 appropriateness 1, 2
- Cartilage evaluation requiring optimal visualization of intra-articular structures - rated 9/9 appropriateness 2
- Suspected ligamentum teres rupture or loose bodies 5
MR arthrography provides superior contrast separation of intra-articular structures compared to non-contrast MRI 2. However, optimized non-contrast MRI protocols can detect 94-95% of labral tears with 92% interobserver agreement 6.
Avoid MRI With and Without IV Contrast:
MRI with and without IV contrast receives low appropriateness ratings (3/9 or lower) for most hip indications and adds unnecessary time, cost, and gadolinium exposure without improving diagnostic yield. 1, 2
This protocol is rated "usually not appropriate" for extra-articular soft tissue abnormalities, labral tears, and post-arthroplasty evaluation 1.
Key Clinical Nuances
When Intravenous Contrast May Add Value:
- Chronic or complex infections where delineating abscess extent increases diagnostic confidence 2, 4
- Complex post-operative cases requiring detailed soft tissue characterization 4
- Bone and soft tissue tumors where vascular characterization aids diagnosis 4
Common Pitfalls to Avoid:
- Do not routinely order IV contrast for hip MRI - the Society of Skeletal Radiology emphasizes judicious gadolinium use, restricting administration to cases with demonstrable added value 4
- Always obtain radiographs first before ordering MRI, as plain films are rated 9/9 for initial evaluation of chronic hip pain 1
- Do not substitute IV contrast for arthrography when evaluating labral pathology - intra-articular contrast (MR arthrography) is the gold standard, not intravenous gadolinium 1, 2
Evidence Strength
The ACR Appropriateness Criteria provide the highest quality guideline evidence, with systematic ratings across multiple clinical scenarios 1. These guidelines consistently rate MRI without IV contrast as "usually appropriate" (7-9/9) while rating MRI with IV contrast as "usually not appropriate" (1-3/9) for the vast majority of hip indications 1.
The 2024 Society of Skeletal Radiology position paper reinforces that contrast is not recommended for routine musculoskeletal MRI, including sports injuries and most hip pathology 4.