Hip Problems, resultant Knee problems and why (in my opinion) you should act sooner rather than later.

Hip woes

As many of my followers and acquaintances will know, in 1996 I was diagnosed with a severely arthritic left hip. At the time I was the Cornell University Men’s and Women’s Squash team Head Coach.

In 1995 I had trained with the teams and had been running very decent cross-country, mile and 400 meter times. Just a year later, I was having trouble running at all. Over the following ten years the situation became worse and worse. Although I continued to play Squash, the physical incapacity progressively made it a miserable experience. I could not find a comfortable position to sleep in. I couldn’t put my socks on. My wife had to do my shoe laces up in public. You get the picture. My limp was so pronounced that I had to swing my left leg around and through in order to be able to walk.

In 1998, my wife and I had moved to Mamaroneck NY, where in partnership with our now dear friends Eric and Patty Fast  we started Westchester Squash, which as the historical record shows, became a wonderfully successful club and launch pad for many junior, collegiate and professional Squash players.

However, that year, I sat miserably at home while all of my fellow Squash competitors went to Los Angeles to compete in the US Championships. The pain of not competing was far worse than the hip.

I decided to play whatever the cost, and in fact, developed some pretty good strategies and control. I even managed to get to the semi-finals of the US National Masters Championships in 2006 having won a very close quarter final with my friend, the former world number 28 Gamal El Amir.

However, because my hip didn’t work properly and because I was not using my body as it ought to have been used, I was putting tremendous pressure on my right knee which was compensating for the incapacity of my left hip.

I had been to see various surgeons in the US. The advice I received was that I was in need of a total hip replacement. Sadly (at that moment in the history of total hip replacement) this would mean an end to serious competitive Squash, as the prostheses then in use would simply not bear the pressure of an impactful game like Squash.

Coincidentally one of my valued friends and clients had recently (Sept. 4th 2005)  watched a CBS 60 minutes program about Medical Tourism in India and a surgeon by the name of Vijay Bose, who was offering Birmingham Hip Resurfacing(BHR).

I started to investigate.

The evidence was very inspiring. BHR was developed in the early nineties by two surgeons in Birmingham, England – Mr. Derek McMinn and Mr. Ronan Treacy.  Their success rate was phenomenal, and serious sports men and women were having the surgery and returning to compete in their favorite sports. Dr. Bose had trained with McMinn and Treacy in England before returning to his native India where he had by this stage performed many BHRs.

At this point BHR was still not FDA approved. My read of the situation was that the American medical community were severely jaundiced by the memory of the metal on metal type Wagner Hip Resurfacing procedure of some thirty or forty years previous. I also had the feeling that surgeons who had trained to do total hip replacement were motivated to encourage total hip replacement and discourage anything that didn’t fit in with their training. It’s possible that I was wrong on this – but that’s the impression I got and the impression a lot of my friends who went to total hip surgeons got.

Anyway,  in the end,  I got in touch with Dr. Bose – sent him my x-rays and decided to go to India. The FDA had approved clinical trials for BHR here, but the quotes were astronomical – $40K-$60K US – quite beyond the capacity of a self employed Squash pro without medical insurance to finance.

The full story of my trip, with my somewhat disgruntled attitude toward the US hip surgeons of 2006 can be found in the link below.

A Hip Trip to India

The success of the surgery is beyond question. Although I did my best to screw things up, because on my return I was overly anxious to get back to full fitness and didn’t rehab thoroughly or professionally. Don’t make that mistake if you do the BHR or other hip resurfacing. When I did focus properly on Rehab, I did 12 weeks with a wonderful Physical Therapist down in Charleston, SC  (where I moved in 2006) and by the end of the time in therapy, felt like I was an Olympic athlete preparing for the next games. I knew that full recovery was going to be a long haul. After all I had allowed 10 years to go by from 96 to 06 and the atrophy on my left side was complete. Additionally the imbalance effects on my right knee were considerable, although (I thought) manageable.

Briefly, my competitive record after surgery was as follows:

2007:

US National Skills 6.0: lost in semi

US Masters 45+: 2nd

2008:

US National Skills 5.5: 2nd

US Masters 45+: 3rd

2009:

US National Skills 5.5:  Winner

US Masters 45+:  2nd

British National 45+: lost in semi

British Open 50+: 2nd ( lost to the legend Ross Norman – what can you expect!?)

Represented England in Home Internationals (first ever appearance for my country of birth).

2010:

US Masters 50+: Winner

British National 50+: Winner

Represented England in Home Internationals and played number 1 (Won all matches).

World Masters ( 50+) in Koln Germany: lost in semi (played OK but having a few knee problems and did catch a cold. No excuses – I was fairly beaten by the Scots no 1 Alan Thomson – who I had beaten earlier in the year in the Home Internationals.)

So you can see that by 2009/2010 my recovery from the BHR was pretty much complete. By late 2010 however, my right knee was giving me quite a few issues and had to be managed on a day to day basis.

Next the Knee

In 2011 I really wanted to retain my British National 50+ title and so I trained mercilessly.  In the lead up to the event in the middle of February, I planned to play a tournament for peaking purposes. This I did, and played quite well – although again the knee was giving me trouble. Of course, when we are focused on a target event,  it is amazing how able we are to ignore symptoms that should be attended to.

I won the peaking event (The North of England Masters 50+) and went back to my parents house in Yorkshire for the three days before the British Nationals started.

On the Monday before my Thursday match,  I decided to go out for a run. I had intended to run for just twenty minutes, but as it was such a beautiful day (and we don’t get many of those in Yorkshire in February) I lost track of time.  Before I knew where I was I had run twenty minutes out and now had to run twenty back. On asphalt.  With a cranky knee. Which was in real pain by the time I got home.

So now I had two days to get ready. I tried anti-inflammatories (I wish I had known about Cheribundi, a tart cherry juice with high anti-inflammatory qualities, in those days). I drank gallons of water.  I tried a leg brace. Which of course was useless.

When the tournament started on Thursday I was in real trouble. However, England Squash and Racketball have some great Physical Therapists on site at the National Center in Manchester and so I was able to get some treatment. But it was traditional Physical Therapy and I had done some real internal damage.

I was  seeded third and made it through the first round – just and iced severely afterwards. In the next match I had to face former PSA pro Simon Rollington – a really tough customer.

I moved really well during the game and didn’t notice my knee. In the semi I had to face my nemesis of the 2010 World masters, number two seed, Alan Thomson.

The knee was sore and unstable, but with some additional physical therapy, I prepared myself.

It was a fabulous match with rallies that wrenched both of us into every possible corner, miss-direction, lunge, sprint, jump and impact that two 50-year-olds could possibly experience.

I won it in four games. In the very last rally, in the act of driving Alan into the backhand back corner that I knew he hated – something bad happened to the knee.

I shook hands and hobbled off the court to go and ice and hopefully prepare for the final against the robust Mark Woodliffe.

As it happened I could have saved my effort. No matter what I did I couldn’t get my knee to the point where I could even put my weight on it.

The next day I did my utmost to warm up, but it was useless. Even in the warm up,  I couldn’t return Mark’s shots. Out of courtesy I tried to play the first game. I lost 0-9 in two minutes, walked over to Mark, apologized and shook his hand.

I went to see a consultant who had a good look at my knee. Shot – was his view. The meniscus was tattered and catching and the tracking of the knee was all over the place.

I arranged to have the Meniscus repaired.  While the surgeon was in there, he took photos of the arthritis. In his opinion if I continued playing, I would need a full knee replacement in less than five years.

I thanked him for his service and went off to rehab (properly this time) fully intending to ignore his advice not to play.

I did rehab well and having had surgery in April of 2011 returned to the US. However, I didn’t feel up to competition.  When Pat and I decided to live in the UK for 6 months, I was really looking forward to playing in British team league.

There’s nothing quite like playing league squash in Britain. 5 man teams competing throughout the winter. You play a hard match for your team, referee (absolutely impartially – which is something we learn growing up in Britain) one of the matches and then sit down for a good meal and some beers with the opposition.

One step up from this is to play for your county – kind of like playing for your state in a mainline sport that has state representation.

On my return to the UK in September of 2011, my county – Norfolk – had to play in the Inter County competition against three other counties in October.  I thought that my knee was recovered sufficiently.

In my first match I discovered that it was still tender. In my second match  I won so quickly that I didn’t realize how much damage I had done. By the time I finished the third match I couldn’t walk properly.

In fact I couldn’t walk properly for about 10 weeks after that. I played for my team in the local league and lost match after match to players that I had never lost to  historically – although I do understand that that happens as you get older. But this was something different. I simply couldn’t change direction.  I couldn’t push off.

I lost and lost.

In the end I just decided that I couldn’t afford to play anymore. The surgeon’s warning about full knee replacement started to really haunt me.

On the comeback trail.

I continued coaching – although even that was problematic. Some of my students were extremely talented and needed good movement from me even to coach them. Players like Jamie Goodrich (who as I write has just won the British Open 40+!) continued to come and work with me and fortunately felt that I was able to give them value. But it was hard work and very depressing.

I started to play a new game that had gained momentum in the UK. The ill-named UK Racketball.  I was a little dubious at first, but as I played more, I discovered what the draw was. This sport has little or no impact on the joints while offering more exercise and rally duration than Squash – especially to masters levels players.

I continued coaching Squash but played the new game almost exclusively. Time passed until one day, toward the end of the season, my captain came to me in desperation and asked me to fill in for the Squash team. I wasn’t keen, particularly when he told me I would be playing against the best number two in the league – my old friend and rival John Cordeaux (at the time of writing John has just lost in the 2012 British Open 50+ semi finals against the self same Mark Woodliffe who was my opponent in 2011 in the final). I didn’t relish this much as I had lost to all the other number twos and John had beaten them. Anyway I agreed to do it for the sake of the team.

The first clue came when I warmed up. The knee pain was much reduced. When we  got into the match, I was moving much better than on the previous occasion I played Squash.  Thus released from pain, I was able to focus on my game plan and proceeded to penalize John (a lefty) in his backhand back corner.  We had a fabulous match – which incredibly I won.

The only thing I can think of with regard to the knee is that by playing the other game I wasn’t subjecting the knee to the kind of impact and stress that regular Squash produces and perhaps was even flushing the knee joint with nutrients because the shorter racket requires a knee bend without a stretch.

Whatever the truth is, something was working, because I continued my regime of playing UK Racketball and only played the league matches of Squash. My Squash improved and so did my results. My knee wasn’t perfect – but it was a lot better.

A signal victory and the way forward.

Pat and I returned to live in Charleston in April.  I started training just around the neighborhood on my bicycle – sometimes doing twenty to thirty minutes pushing as hard as I could  and sometimes doing one minute wind sprints – usually just four or five.

I was training three days per week and alternating the bicycle sessions with a medicine ball program that I developed using some of the information that Damon Leedale Brown had shared with me and some sports specific medicine ball routines (more on the medicine ball training for squash shortly) that I had developed myself.

Working freelance as a Squash coach, my schedule was quite irregular. I was traveling to do some work for my friend Dominic Hughes at his Berwyn Squash and Fitness club in PA and also working in Charlotte and the Research triangle area.  I discovered that I was free on the weekend of the US Skill Level nationals at Meadow Mill Athletic Club in Baltimore and as the US was asking for late entrants – I entered on the spur of the moment.

It was something of a baptism of fire. Based on my previous rating they seeded me number one (I had won the event a couple of years previously).  My first round match was against a talented young man from Atlanta, Danial Saleem, who I discovered was now at the rapidly improving Columbia Uni program headed up by SA coach Jacques Swanepoel.  I had last seen Danial when he and his family came to work with me for a long weekend training session in Charleston when he was 16.  Naturally expecting the same player as I had worked with then,  I received a sharp affront to my senses as I discovered that he had matured considerably. We had a great game, but he managed to retrieve just about everything I played.  He won 3-1 (and progressed to the semi finals eventually before losing to the winner of the event). Meanwhile I found myself in the consolations. I wasn’t too bent out of shape about this – after all, I had entered on a whim and didn’t even know if I could compete after the trials and tribulations of the previous few months.

In the consolations I had a quick win and then a hard five-set win to take the consolation trophy – and came away reasonably satisfied and more importantly injury free.

On the strength of this performance (and because it coincided with my sister in law’s return to the UK after visiting with us)  I decided to enter the Canadian nationals in May.  Having missed both the British and the US Nationals I was excited to get a nationals “fix” especially as I had never played the Canadians before.

I entered the Rothenberg Big Apple Open the weekend before the Canadians as I needed a peaking tournament (although I would have preferred it to be two weeks before – one week doesn’t really give enough recovery) and it also happened to fit with our family travel plans.

I played very well in the Rothenberg – losing in a fine match in the final to another Columbia Uni player (have these boys got a vendetta going?) – their number 2 Tony Zou.  I felt fit and the knee didn’t hurt, although I was pretty exhausted.

I spent the next few days doing some light coaching and then visited with some friends. There was no knee pain on the Monday or Tuesday after the Rothenberg, but then mysteriously on the Wednesday it began to ache and give me some trouble.

Ominous.

I have fully recounted the story of my Canadian Nationals win in a previous blog.

With the combination of Cheribundi and Dr. Joe Pelino,  my cranky knee was not only managed but came back to competitive form.

I want to say a few words about the technique that Dr. Joe Pelino used to get my knee working. It’s called Active Release Therapy and is available throughout North America from a network of trained therapists.

I had never experienced it before – despite having worked with some first class physical therapists. The way it worked for me was by seemingly changing the pressure on various structures around the knee and allowing the knee to function without pain.

I can’t say that it will work for everyone, but the effect on me was tangible and dramatic. I will definitely continue with it whenever I can.

Dr. Joe also advised me that it is not only possible but necessary to rebuild cartilage in the knee joint by using supplements such as glucosamine and chondroitin but by actually consuming plenty of cartilage from meat such as Chicken wings. This I have been doing – and it really seems to work.

So to conclude:

Dr. Vijay Bose transformed my life by giving me the BHR operation in 2006.  I wish  I had sought him out years before.

If I had,  perhaps the over compensation on my right side which led to the breakdown of my right knee might not have occurred.

If I hadn’t gone running on the road when I was already tired and the knee was inflamed perhaps I might have been able to give my defense of my British Closed title 100 percent.

Being that the knee breakdown did occur, I am delighted that I discovered the relatively impact free sport of UK Racketball that I am now developing into a new sport and that I think could well impact (no pun intended) millions of enthusiastic players world wide, offering them both a great cross-training opportunity and a wonderful, diverting game in and of itself.

If my knee hadn’t caused me so much trouble I doubt I would have discovered “Active Release Therapy” (ACT) which I think will be a massive boon and relief to many Squash players.

And finally the advent of Cheribundi has been an additional bonus that I may well have discovered anyway but not to the same extent of relieving my aches and pains.

Overall by either ignorance or over enthusiasm leading to bad decisions,  I have made choices that were avoidable and that hopefully you – the reader – can avoid.

Nevertheless as my friend O Wayne Hodges is fond of saying “Every decision you make is the right decision in the end,” and my bad ones have led to discoveries that have benefited me and hopefully will benefit you.

If you have any questions please don’t hesitate to contact me either here or at Millmansquash@gmail.com

Richard Millman

May 22nd, 2012