Shoulder MRI Report Template: Normal Example and Rotator Cuff Checklist

Normal shoulder MRI report: complete example

This framework is for a routine MRI of one shoulder without intra-articular contrast. Confirm laterality and whether the study is conventional MRI, direct MR arthrography, or an examination tailored to postoperative change, infection, or a mass. The template is a starting point for wording, not evidence that every structure is normal.

Examination: MRI of the left shoulder without intravenous or intra-articular contrast.

Clinical indication: [Indication.]

Comparison: [Prior study and date / None available.]

Technique: Multiplanar, multisequence MRI of the left shoulder was performed without intravenous or intra-articular contrast.

Findings: The osseous alignment is maintained. Marrow signal is within expected limits, without acute fracture or focal marrow lesion. The supraspinatus, infraspinatus, subscapularis, and teres minor tendons are intact, with no significant tendinosis. Rotator cuff muscle bulk is preserved. The long head of the biceps tendon is intact and normally positioned in the bicipital groove. No displaced labral tear is identified on this routine examination. Glenohumeral cartilage is maintained. No significant joint effusion or distention of the subacromial-subdeltoid bursa is present. The acromioclavicular joint and visualized soft tissues show no significant abnormality.

Impression: No significant abnormality identified on routine MRI of the left shoulder.

Use only the sentences supported by the acquired sequences. A routine shoulder MRI and a direct MR arthrogram answer related but distinct questions; do not describe the former as an arthrogram.

Before interpretation

• Verify the side on the images and order, and review the clinical question, prior imaging, and history of dislocation, trauma, injection, or surgery.
• Confirm whether contrast was injected into the joint. State intravenous and intra-articular contrast separately; they are not interchangeable.
• Check image quality, coverage of the cuff and muscle bellies, and susceptibility from hardware. Note limitations that affect a specific structure.
• Use the surgical history when reviewing a repaired cuff, biceps tenodesis, labral repair, or arthroplasty. Compare with prior imaging when available.

A practical review sequence

Rotator cuff and muscles

Trace the supraspinatus, infraspinatus, subscapularis, and teres minor from muscle to tendon insertion. For tendinopathy, describe the tendon and its location without implying a tear. If a tear is present, report the involved tendon, side of the tendon (articular, bursal, or intrasubstance for a partial tear), full- versus partial-thickness extent, dimensions when measurable, and tendon retraction. Assess muscle volume and fatty change when relevant, especially in a substantial tear or preoperative study. Avoid declaring a tear “repairable” from imaging alone.

Long head of the biceps and pulley

Follow the intra-articular and groove portions of the long head of the biceps tendon. Check continuity, caliber, signal, position, sheath fluid, and the biceps pulley/rotator interval when included. A tendon that is not seen in its expected position may be torn, displaced, or outside the coverage; state the evidence and limitation rather than assuming one cause.

Labrum, capsule, and cartilage

Review the labrum, glenohumeral cartilage, joint capsule, and major ligaments in the context of the protocol and clinical question. A displaced labral fragment, paralabral cyst, or clear detachment may be visible on conventional MRI, but subtle labral and capsuloligamentous abnormalities may require a dedicated protocol. Do not assign a SLAP or instability diagnosis from equivocal signal alone.

Outlet, joint, and surrounding structures

Review the acromion, acromioclavicular joint, subacromial-subdeltoid bursa, marrow, synovium, and visible muscles and soft tissues. Report a relevant os acromiale, osteophyte, bursal distention, marrow lesion, or effusion when present. An anatomic feature by itself does not prove a pain mechanism.

Selected abnormal wording

Tendinopathy: Mild tendinosis of the distal [supraspinatus / infraspinatus / subscapularis] tendon without a discrete tear.

Partial-thickness tear: Partial-thickness [articular-sided / bursal-sided / intrasubstance] tear of the distal [tendon], measuring approximately [dimensions] where measurable. No full-thickness defect is identified.

Full-thickness tear: Full-thickness tear of the [tendon] measuring approximately [anteroposterior dimension] with [degree of] medial retraction. [Rotator cuff muscle volume is preserved / There is associated muscle atrophy and fatty change.]

Long head of biceps: Mild tendinosis of the intra-articular long head of the biceps tendon. The tendon remains located in the bicipital groove.

Labrum: [Location]-predominant labral tear is suspected/identified on this [routine MRI / direct MR arthrogram]. [A paralabral cyst is present at …]. Correlate with the acquisition and clinical question.

Do not give a partial tear a numerical grade unless your department uses an explicit, consistently applied scheme. If a lesion's location or surface cannot be determined confidently, say so.

Fictional worked example: supraspinatus tear

This teaching case is fictional. The measurements are illustrative and should not be copied into another examination.

Examination: MRI of the right shoulder without intravenous or intra-articular contrast.

Clinical indication: Persistent shoulder pain.

Comparison: Right shoulder radiographs dated [date].

Technique: Multiplanar, multisequence MRI of the right shoulder was performed without intravenous or intra-articular contrast.

Findings: There is a full-thickness tear of the distal anterior supraspinatus tendon, measuring approximately 12 mm in anteroposterior width, with 9 mm of medial tendon retraction. Mild background supraspinatus tendinosis is present. The remaining rotator cuff tendons are intact. Rotator cuff muscle bulk is preserved without significant fatty change. The long head of the biceps tendon is intact and normally located. No displaced labral tear is identified on this routine examination. There is mild acromioclavicular osteoarthritis and trace fluid in the subacromial-subdeltoid bursa. Glenohumeral cartilage is maintained. No acute fracture or focal marrow lesion is identified.

Impression:
1. Full-thickness tear of the distal anterior supraspinatus tendon, approximately 12 mm in anteroposterior width with 9 mm of retraction.
2. Mild acromioclavicular osteoarthritis.

The impression prioritizes the tear and preserves its measured extent. It does not infer chronicity, symptom causation, or surgical suitability.

Routine MRI, arthrography, and limits

Routine noncontrast MRI provides a broad assessment of the cuff, long head of the biceps, labrum, cartilage, bone, and surrounding tissues. Direct MR arthrography adds intra-articular contrast after injection and may be selected for specific intra-articular questions, including when conventional MRI is indeterminate or discordant with the clinical assessment. It is a separate procedure and should be named accurately in the technique.

MRI is a static examination. It does not reproduce dynamic impingement or instability testing. Image quality, field strength, positioning, postoperative change, and the question being asked affect how confidently a structure can be assessed. If a structure is not adequately shown, qualify the report instead of using a broad normal statement.

Common wording pitfalls

• Saying “normal labrum” when a routine study does not confidently assess subtle labral disease.
• Calling tendinosis a tear, or using “partial tear” without identifying the tendon and affected surface when visible.
• Reporting a full-thickness cuff tear without its location and measurable extent when these can be stated.
• Using “impingement” as a causal diagnosis based only on acromial shape or mild bursal fluid.
• Calling a tear acute, chronic, repairable, or the cause of symptoms without supporting evidence.
• Treating a routine MRI as if it included intra-articular contrast or specialized instability positioning.
• Using a native-shoulder normal template after repair or arthroplasty without accounting for altered anatomy and artifact.

Primary references

• American College of Radiology, Society for Pediatric Radiology, Society of Skeletal Radiology. Practice Parameter for the Performance and Interpretation of MRI of the Shoulder. Revised 2024, Resolution 18. Official practice parameter (opens in a new tab)
• Chang EY, Bencardino JT, French CN, et al. SSR white paper: guidelines for utilization and performance of direct MR arthrography. Skeletal Radiology. 2024;53:209–244. doi:10.1007/s00256-023-04420-6 (opens in a new tab)
• Tawfik AM, El-Morsy A, Badran MA. Rotator cuff disorders: How to write a surgically relevant magnetic resonance imaging report? World Journal of Radiology. 2014;6(6):274–283. doi:10.4329/wjr.v6.i6.274 (opens in a new tab)

This educational framework does not replace patient-specific interpretation, current local protocols, or clinical judgment.