Is an MRI with or without contrast recommended for a patient with tendonitis and paresthesia?

MRI for Tendonitis with Paresthesia: Without Contrast

For tendonitis evaluation, MRI without IV contrast is the appropriate imaging modality, and contrast is not routinely indicated unless there is specific concern for infection or inflammatory arthropathy. 1

Standard Imaging Protocol for Tendonitis

• MRI without IV contrast is the primary recommendation for evaluating tendon abnormalities including tendinopathy, tendon tears, and tenosynovitis 1
• The contrast resolution of MRI makes it ideal for assessing soft tissue abnormalities without requiring intravenous contrast 1
• MRI without contrast can diagnose the full spectrum of tendon pathology including tendinopathy, partial tears, complete tears, intersection syndrome, and stenosing tenosynovitis 1

When to Consider Adding Contrast

Contrast-enhanced MRI should be reserved for specific clinical scenarios:

• Detection of tenosynovitis: Adding IV contrast improves sensitivity for detecting tenosynovitis compared to T2-weighted sequences alone 1, 2
• Suspected inflammatory arthropathy: When rheumatoid arthritis or seronegative spondyloarthropathy is suspected, MRI with contrast helps distinguish synovitis from joint effusion and ganglion cysts 1, 2
• Suspected infection: If septic arthritis or soft tissue infection is a concern, contrast-enhanced imaging is appropriate 1

Addressing the Paresthesia Component

The paresthesia requires additional diagnostic consideration beyond tendon imaging:

• Paresthesia suggests nerve involvement, which may indicate nerve entrapment, compression, or neuropathy 3
• Ultrasound is highly effective for evaluating nerve entrapment by demonstrating nerve enlargement, hypoechogenic appearance, and intraneural vascularity 3
• MRI without contrast can assess nerves, tendons, and surrounding soft tissues simultaneously 1
• Consider that paresthesia with tendonitis may indicate carpal tunnel syndrome or other entrapment neuropathy, where ultrasound offers diagnostic advantages 1, 3

Practical Algorithm

Follow this stepwise approach:

1. Begin with plain radiographs to rule out bony abnormalities, fractures, or arthritis 2, 4
2. Order MRI without IV contrast as the next study for tendon evaluation 1, 2
3. Consider ultrasound as an equivalent alternative if the pathology is superficial and dynamic assessment would be helpful 1, 2
4. Add contrast only if there is clinical suspicion for inflammatory arthropathy, infection, or if initial non-contrast imaging shows tenosynovitis requiring better characterization 1, 2

Common Pitfalls to Avoid

• Do not order MRI with contrast routinely for tendon evaluation—there is no relevant literature supporting routine contrast use for standard tendinopathy 1
• Do not skip initial radiographs—they must be obtained first to rule out obvious bony pathology 2, 4
• Do not ignore the paresthesia—this symptom warrants evaluation for nerve pathology, potentially with ultrasound or electrodiagnostic studies 3
• Recognize that ultrasound may be superior for superficial tendon pathology and nerve entrapment, offering dynamic assessment and lower cost 2, 4, 5