Select Page

Membership Dashboard >> Research and Technique Reviews >> Shoulder MRI: Contrast or Not?

SHOULDER MRI: Contrast or Not?

Ordering the correct imaging is crucial for an accurate diagnosis. This article reviews distinctions between conventional MRI and MR arthrography.

The Basics:

Conventional MRI is the standard MRI without contrast. The advantage here is the procedure is non-invasive. The disadvantage is there is a diminished sensitivity for many types of shoulder pathology.

MR arthrography uses an injection of contrast that is delivered into the joint under fluoroscopic guidance. This is slightly invasive as the injection can cause infection and some people have reactions to the contrast itself. The advantage is increased sensitivity of shoulder pathology.

Research:

There are many research articles that have investigated shoulder pathology and MRI. Typical studies will MRI the patient using conventional MRI and again using MR arthrography. Then the patient undergoes surgery (arthroscopy) during which the pathology is assessed. The surgical findings are compared with each type of MRI.1,2

Results:

MR arthrography showed significant increased sensitivity for detection of partial-thickness articular surface supraspinatus tears, anterior labral tears, and SLAP tears compared with conventional MRI.

Anatomy

MRI

MR Arthrography

Anterior Labrum Tear

83%

98%

Posterior Labrum Tear

84%

95%

SLAP Lesions

83%

98%

Supraspinatus Tendon Tears

92%

100%

 

As you can see, there is an approximately 12% increased chance of detecting a tendon/cartilage lesion when MR arthrography is utilized vs. conventional MRI.

Application:

The authors recommend performing MR arthrography on patients for whom anterior labral tears, SLAP tears, and partial-thickness supraspinatus tendon tears are suspected clinically– as these groups had the highest statistical significance. 

When I order an MRI for the shoulder I almost always order the MR arthrography. The question is simple: Do you want sensitivity in the low 80’s or the middle 90’s? The biggest problem with conventional MRI is after the test comes back negative. The provider and patient have a false test and pursue treatment (wasting time, money and energy) on fixing a problem that may require surgery.

My advice: Go with the MR arthrography.

When to order an MRI?

I usually suspect cartilage damage/degeneration/tears for several reasons:

  1. Pain with full/excessive range of motion, particularly if symptoms are in the middle of the range (paiful arc).
  2. Symptoms improve with treatment but last only minutes to hours. Treatment is only making reflex changes (reducing hypertonicity).
  3. Patient improves then hits a plateau. Treatment will reduce much of the dysfunction and improve the symptom/function picture but not completely. The remaining problem is irreducible with conservative treatment- so some level of dysfunction is still present and needs to be identified.
  4. Symptoms revert to near baseline after making substantial progress. This often happens because the treatment is working and the patient is being careful, but the problem is still there. Often trivial insult or light use will cause the symptoms to come back to near baseline intensity.
  5. The provider passively flexes the patients shoulder in the supine position and produces posterior pinching of the joint combined with a palpable lack of tension in the subscapularis.

If any of the above situations occur I am strongly considering ordering MR arthrography for the shoulder. Exactly when you do this is up to your individual judgment. The more experience you have and the more you can trust your palpation the more clear the need to order imaging becomes.

Ordering:

It is very important to use the proper verbiage when ordering MR arthrography. I can’t tell you how many times the orthopedist or radiologist ignores your request and orders a plain MRI instead. Some of these docs are just dismissive of anyone but themselves.

Include the following points in your order or request:

1.       Conservative treatment has failed to make expected progress.

a. Mr. X has been under my care for 10 visits and has only improved 25%.

2.       The suspected pathology with the reasons why you suspect it.

a. Example: I suspect the remainder of Mr. X’s symptoms are due to a degenerative SLAP lesion. Soft tissue palpation reveals no abnormalities while there is an altered joint axis of rotation evidenced by superior pinching of the GH joint with abduction.

3.       Explicitly state your request for MR arthrography.

a. I am requesting MR arthrography of the left shoulder as I suspect XYZ pathology and MR arthrography has consistently demonstrated better sensitivity than conventional MRI.

1. Magee T. 3-T MRI of the shoulder: is MR arthrography necessary? AJR Am J Roentgenol. 2009 Jan;192(1):86-92.

2. Waldt S. et al. Diagnostic Performance of MR Arthrography in the Assessment of Superior Labral Anteroposterior Lesions of the Shoulder AJR 2004; 182:1271-1278

William F. Brady, DC 

September 9, 2009 

SUBLUXATION?

SUBLUXATION?

Membership Dashboard >> Research and Technique Reviews >> Subluxation? SUBLUXATION?Let's face it, the chiropractic definition of subluxation is not going away. A proper understanding of subluxation it's meanings and components will help improve...

Seminar Review: 2011 Chiropractic Sports Sciences Symposium

Seminar Review: 2011 Chiropractic Sports Sciences Symposium

Membership Dashboard >> Research and Technique Reviews >> Seminar Review: 2011 Chiropractic Sports Sciences Symposium  Seminar Review: 2011 Chiropractic Sports Sciences SymposiumOn April 7-10, 2011 the American Chiropractic Board of Sports Physicians held...

Research Review: Thessaly Test for Detection of Meniscal Tears

Research Review: Thessaly Test for Detection of Meniscal Tears

Membership Dashboard >> Research and Technique Reviews >> Research Review: Thessaly Test for Detection of Meniscal TearsRESEARCH REVIEW: Thessaly Test for Detection of Meniscal TearsA recent article in Dynamic Chiropractic highlighted research showing...

Book Review: The Logic of Failure

Book Review: The Logic of Failure

Membership Dashboard >> Research and Technique Reviews >> Book Review: The Logic of FailureBOOK REVIEW: The Logic of FailureI first read The Logic of Failure in 1997, I have to say it is pure genius! The author, Dietrich Dorner, explains in exquisite...

Technician vs. Doctor

Technician vs. Doctor

Membership Dashboard >> Research and Technique Reviews >> Technician vs. DoctorTECHNICIAN vs. DOCTORBy William F. Brady, DC Dynamic Chiropractic – September 10, 2007, Vol. 25, Issue 19 A new distinction is emerging in the chiropractic profession. The...

Back Pain Literature: What Have We Learned?

Back Pain Literature: What Have We Learned?

Membership Dashboard >> Research and Technique Reviews >> Shoulder MRI: Contrast or Not?Back Pain Literature: What have we learned? By William F. Brady, DC for Dynamic ChiropracticDecember 14, 2000 Update Note 2016: This is a trip down memory lane. These...

Knee Adduction Moment: Load, Symptoms and Pathology Progression

Knee Adduction Moment: Load, Symptoms and Pathology Progression

Membership Dashboard >> Research and Technique Reviews >> Knee Adduction Moment: Load, Symptoms and Pathology ProgressionKnee Adduction Moment: Load, Symptoms and Pathology ProgressionThe Knee Adduction Moment (KAM) is a very sophisticated measurement of...

Thoracic Dysfunction and Shoulder Impingement

Thoracic Dysfunction and Shoulder Impingement

Membership Dashboard >> Research and Technique Reviews >> Thoracic Dysfunction and Shoulder ImpingementThoracic Dysfunction and Shoulder ImpingementCo-occurence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic...