Shoulder MRI: Standard Non-Contrast vs. Contrast-Enhanced Arthrogram
For an adult with shoulder pain, limited range of motion, and suspected rotator cuff pathology or osteoarthritis, order a standard non-contrast shoulder MRI as the initial advanced imaging study. 1
Primary Recommendation Based on Clinical Presentation
Standard MRI without contrast (rated 9/9 "usually appropriate") is the optimal first-line imaging for rotator cuff disease and degenerative pathology in adults, particularly those over 35-40 years. 1 The 2025 ACR Appropriateness Criteria explicitly state that non-contrast MRI has high sensitivity and specificity for detecting full-thickness rotator cuff tears and provides excellent visualization of tendinosis, muscle atrophy, fatty infiltration, and osteoarthritic changes—all critical findings for surgical planning and prognosis. 1
Why Non-Contrast MRI is Preferred for Your Clinical Scenario
Full-thickness rotator cuff tears are accurately identified on conventional non-contrast MRI, with signal intensity extending from inferior to superior tendon surface serving as a reliable diagnostic sign. 1
Tendinosis, muscle atrophy, tendon retraction, and fatty infiltration—the key prognostic features that guide conservative versus operative management—are all optimally visualized without contrast. 1
Osteoarthritis evaluation (glenohumeral joint space narrowing, cartilage loss, subchondral changes, osteophytes) does not require intra-articular contrast and is well-assessed on standard sequences. 2
Non-contrast MRI provides comprehensive assessment of bone marrow edema, bursitis, acromioclavicular joint pathology, and other causes of shoulder pain in a single examination. 1
When to Consider MR Arthrography Instead
MR arthrography (rated 9/9) should be reserved for specific clinical scenarios where standard MRI is insufficient: 1
Age-Based Indication
- Patients under 35 years with suspected instability or labral pathology should proceed directly to MR arthrography, as instability predominates in this age group and the intra-articular gadolinium provides superior capsulolabral visualization. 1, 3
Diagnostic Uncertainty
When distinguishing between full-thickness and partial-thickness rotator cuff tears is clinically critical and standard MRI findings are equivocal, particularly when abnormal signal extends from the undersurface of the tendon. 1
MR arthrography demonstrates increased sensitivity for partial-thickness articular surface tears compared to conventional MRI, though this distinction often does not change initial conservative management. 1
Post-Operative Evaluation
- Suspected retear after prior rotator cuff repair: Both MRI without contrast and MR arthrography are rated equally (9/9) for this indication, with choice depending on local expertise and clinical context. 1
Critical Clinical Algorithm
Follow this decision pathway:
Patient age ≥35-40 years + suspected rotator cuff disease or osteoarthritis → Standard MRI without contrast 1
Patient age <35 years + suspected instability or labral tear → MR arthrography 1, 3
Acute trauma with joint effusion/hemarthrosis → Standard MRI without contrast (natural contrast from fluid) 1
Equivocal partial-thickness tear on initial non-contrast MRI requiring definitive characterization → Consider MR arthrography as problem-solving tool 1
Important Caveats and Pitfalls
Do not order MR arthrography routinely for rotator cuff evaluation in patients over 35 years—the invasive intra-articular injection adds cost, patient discomfort, and procedural risk without improving detection of full-thickness tears or providing additional prognostic information about muscle quality. 1
The distinction between partial-thickness and full-thickness tears often does not alter initial conservative management (rest, physical therapy, NSAIDs), making the superior sensitivity of MR arthrography for partial tears clinically irrelevant in many cases. 1
Ultrasound is an equivalent alternative (rated 9/9) for rotator cuff evaluation when performed by experienced operators, offering dynamic assessment and cost-effectiveness, though it provides limited evaluation of labral structures, bone marrow, and deep soft tissues. 1
Avoid gadolinium-based contrast in patients with severe renal dysfunction (GFR <30 mL/min/1.73 m²) or dialysis-dependence due to nephrogenic systemic fibrosis risk. 1
Practical Implementation
For your specific patient with shoulder pain, limited ROM, and possible rotator cuff or osteoarthritis:
Order: MRI shoulder without IV contrast 1
Ensure the protocol includes: T1-weighted sequences (for anatomic detail and fatty infiltration), T2-weighted fat-saturated sequences (for fluid-sensitive detection of tears and edema), and oblique coronal and sagittal planes aligned with the supraspinatus tendon. 1
Reserve MR arthrography for the uncommon scenario where initial non-contrast MRI shows equivocal undersurface signal abnormality and surgical decision-making hinges on definitively excluding versus confirming a partial articular-surface tear. 1