In myotonic dystrophy type 1 (DM1), MRI shows a characteristic pattern of skeletal muscle involvement, and data are usually in line with the clinical presentation. In contrast, myotonic dystrophy type 2 (DM2) patients often show discrepancies between their clinical phenotype and MRI. Systematic data on MRI abnormalities and their histological correlates are not available to date. We analyzed Vastus Lateralis biopsies, corresponding 3T MRI, and clinical data in 1 DM1 (f, 150–200 CTGs; MIRS IV; ages at biopsy/MRI: 49/50 y) and 6 DM2 patients (f/m:3/3). In DM2, mean ages at biopsy and subsequent MRI examinations were 53.7+/−12.2 y and 57.7+/−13.3 y, respectively. 3 female DM2 patients had pathological MRI results indicative of fatty degeneration: 2 patients showed moderate fatty changes, 1 patient had a complete fibroadipose tissue replacement. The corresponding histological findings included increased fiber size variation, type I fiber predominance, increased numbers of internal nuclei, numerous pyknotic nuclear clumps, acid phosphatase-positive sarcoplasmic granules in normal appearing and/or degenerative fibers, and widespread fatty tissue replacement in all 3 patients, and results correlated well with the extent of MRI changes. Further 3 DM2 patients had normal MRI, however also showed histological abnormalities which were milder and included type I fiber predominance, type II fiber atrophy, an increase of internal nuclei, and numerous pyknotic nuclear clumps but no fatty degeneration. In DM1, MRI of Vastus Lateralis was normal. The histological findings were in line and showed only mild variations in fiber size and few nuclear clumps. In DM, histological and imaging findings correlated well with the clinical data on muscle strength of knee extensors. We conclude that MRI most reliably reflected fatty tissue replacement in vivo. In contrast, changes in fiber type distribution, abnormal position of myonuclei, and numerous nuclear clumps did not show MRI correlates.