Normal Shoulder MRI Report Template

Normal shoulder MRI report template: rotator cuff tendon by tendon, labrum, long head of biceps, AC joint and muscle bulk, with cuff tear wording notes.

EXAMINATION: MRI [right/left] shoulder without intravenous
contrast.

CLINICAL HISTORY: [indication]

COMPARISON: None available.

TECHNIQUE: Multiplanar, multisequence MR imaging of the [right/left]
shoulder without intravenous contrast.

FINDINGS:
Rotator cuff:
  Supraspinatus: Intact. Normal signal and morphology. No tear.
  Infraspinatus: Intact. No tear.
  Teres minor: Intact.
  Subscapularis: Intact. No tear.
Rotator cuff muscles: Normal bulk. No fatty atrophy or edema.
Labrum: Normal signal and morphology on this non-arthrographic
examination. No displaced labral tear.
Long head of biceps tendon: Normally located within the bicipital
groove. Intact.
Glenohumeral joint: Congruent. Articular cartilage is preserved. No
significant joint effusion.
Acromioclavicular joint: Unremarkable. No significant arthrosis or
inferiorly directed osteophyte.
Bones: Normal marrow signal. No fracture or Hill-Sachs deformity.
Bursae: No subacromial-subdeltoid bursal fluid.
Soft tissues: Unremarkable.

IMPRESSION:
1. Intact rotator cuff. No labral tear identified.

Dictation notes

• A cuff tear is reported in surgical terms: which tendon, partial versus full thickness, articular or bursal surface, tear dimensions and retraction in centimeters.
• A medially subluxed biceps tendon means the subscapularis is torn until proven otherwise — check them as a pair.
• Fatty atrophy (Goutallier grade) decides repairability, so comment on muscle bulk even when every tendon is intact; labral sensitivity is limited without arthrography, and the report should say so in the young instability patient.

Frequently asked questions

What does a normal shoulder MRI report cover?

A shoulder MRI report addresses each rotator cuff tendon by name — supraspinatus, infraspinatus, teres minor and subscapularis — plus muscle bulk and fatty atrophy, the labrum, the long head of the biceps tendon and its position in the bicipital groove, the glenohumeral joint and cartilage, the acromioclavicular joint, marrow signal, and the subacromial-subdeltoid bursa. The normal impression states an intact rotator cuff with no labral tear identified.

How should a rotator cuff tear be described on MRI?

In surgical terms: which tendon is torn, partial versus full thickness, articular or bursal surface for partial tears, the tear dimensions, and the degree of tendon retraction in centimeters. Muscle quality matters as much as the tear itself — fatty atrophy, graded by the Goutallier classification, decides repairability — so the report should comment on muscle bulk even when every tendon is intact. A medially subluxed biceps tendon implies a subscapularis tear until proven otherwise.

How reliable is non-arthrographic MRI for labral tears?

Sensitivity for labral tears is limited on conventional MRI without intra-articular contrast, and the report should say so in the young instability patient rather than imply the labrum was fully excluded. MR arthrography distends the joint and outlines labral detachments directly, making it the preferred study when instability is the clinical question. A normal conventional study is reasonably worded as 'no displaced labral tear on this non-arthrographic examination.'

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