Is an MRI with or without contrast ordered for shoulder rotator cuff pathology?

MRI Without Contrast for Rotator Cuff Pathology

For suspected rotator cuff pathology, order MRI shoulder WITHOUT intravenous contrast as the primary imaging modality. 1

Rationale for Non-Contrast MRI

MRI without IV contrast is the optimal imaging study for rotator cuff evaluation because it provides superior soft tissue visualization and has high diagnostic accuracy for detecting both full-thickness and partial-thickness tears. 1, 2

• The American College of Radiology 2025 guidelines explicitly state that MRI shoulder without IV contrast is "generally considered the best modality for adequately assessing most soft tissue injuries, including labroligamentous, cartilage, and rotator cuff pathology." 1

• Non-contrast MRI demonstrates high sensitivity and specificity for full-thickness rotator cuff tears, with performance comparable to MR arthrography (sensitivities 90-91%, specificities 93-95%). 1, 3

• In the acute post-traumatic setting, post-traumatic joint effusion or hemarthrosis naturally distends the joint, providing sufficient visualization of soft tissue structures without requiring intra-articular contrast injection. 1, 2

When MR Arthrography (With Contrast) May Be Considered

MR arthrography is not the initial study for rotator cuff evaluation, but has specific limited indications: 1

• Partial-thickness tears: MR arthrography has higher sensitivity than non-contrast MRI for detecting partial-thickness rotator cuff tears when conventional MRI is equivocal. 1, 2

• Subacute or chronic presentations: In non-acute settings where glenohumeral joint effusion is too small to provide adequate joint distention, MR arthrography may be appropriate for detailed soft tissue assessment. 1

• Labral pathology: When detailed evaluation of labral tears is the primary concern alongside rotator cuff assessment, MR arthrography may be appropriate. 1

Imaging Algorithm

1. Initial radiographs first: Always obtain plain radiographs (AP views in internal and external rotation plus axillary or scapular Y view) to exclude fractures, dislocations, and osseous pathology before advanced imaging. 1, 2, 3

2. MRI without contrast as next step: If radiographs are normal or nonspecific and rotator cuff pathology is suspected, proceed directly to MRI shoulder without IV contrast. 1, 3

3. Consider ultrasound as alternative: In specific scenarios—such as patients with proximal humeral hardware causing MRI artifacts, MRI contraindications, or when local ultrasound expertise is available—ultrasound may be appropriate as it has similar diagnostic performance for full-thickness tears. 1, 3

Why NOT Intravenous (Non-Arthrographic) Contrast?

Standard intravenous gadolinium contrast (not injected into the joint) provides no additional diagnostic benefit for rotator cuff evaluation and unnecessarily exposes patients to contrast-related risks. 1

• The ACR guidelines consistently recommend MRI "without IV contrast" specifically, not "with and without" or "with IV contrast." 1, 3

• Intravenous contrast does not enhance tendon visualization and is reserved for evaluating infection, tumor, or inflammatory conditions—not routine rotator cuff tears. 1

Critical Pitfalls to Avoid

• Do not order CT: CT without contrast has virtually no role in diagnosing soft tissue injuries such as rotator cuff tears and should not be used for soft tissue evaluation. 2, 3

• Do not skip initial radiographs: Plain films are mandatory first to exclude fractures, dislocations, and superior humeral head migration that may indicate chronic massive tears. 2, 3

• Do not routinely order MR arthrography initially: Reserve MR arthrography for cases where non-contrast MRI is equivocal for partial-thickness tears or when labral pathology requires detailed assessment. 1, 2

• Avoid gadolinium in renal failure: In dialysis-dependent patients or those with severe renal dysfunction (GFR <30 mL/min/1.73 m²), avoid all gadolinium-based contrast agents due to nephrogenic systemic fibrosis risk. 1