kayakers shoulder

Hi

Just wondering if anyone could throw some light on a patient I have at the moment. He's a white water kayaker and its also his profession - very high level, with lots of crazy forces being put on the shoulders.

He came to me about 3 months ago, with right shoulder trouble, with 2 distinct areas of pain - postero-superior pain catching at 70-110 degress, and also minor pain around anterior capsule. He had an ultrasound which said small sub deltoid bursitis and minor bicipes calcification, but I've since been told that that report was unreliable...He looked pretty straightforward rotator cuff trouble with secondary impingement, bad scapular control, winging etc. He got a low grade injection and lots of stability excs and rotator cuff control work. Pain in rotator cuff insertion area quickly resolved but over the past 2 months the anterior capsule pain has gotten much much worse - now in BOTH shoulders. Even simple ADLS, computer, writing etc are flaring his pain he says.

He has been out of action now for nearly 4 months and this is his livlihood. Sports musculoskel is not my area of physio, which I've told him. We're in Uganda and resources are not great so really I'm all he's got - HELP!

I did refer him to a good ortho surgeon here to have him look at them, I was thinking labral tears, even though the 3 clinical tests were coming up negetive. MRI revealed nothing, doc thought it was bicipital tendinitis bilaterally and did another injection anteriorly into the right to see if it would help before doing the left, but no improvements.

I dont really know what else to do. He's a really good patient, adhereing to physio totally. We've been mostly doing posterior capsular stretching coz poor internal rotation, lots of scapular work, thoracic extension work and rotations - he does have 2 small scoliosis which I know is having impact on technique. lots of core work. But we've had to cut out biceps stretching which was flaring too much. Anterior capsule seems a bit lax,

ANy further advice would be greatly appreciated.
Any other suggestions for diagnosis?

thank you!