Platelet-Rich Plasma (PRP): Is Ray Lewis' Other 'Substance' Speeding Recoveries?

Dave Siebert, M.D.@DaveMSiebertFeatured ColumnistFebruary 1, 2013

NEW ORLEANS, LA - JANUARY 30:  Linebacker Ray Lewis #52 of the Baltimore Ravens walks on stage to address the media during Super Bowl XLVII Media Availability at the Hilton New Orleans Riverside on January 30, 2013 in New Orleans, Louisiana. The Ravens will take on the San Francisco 49ers on February 3, 2013 at the Mercedes-Benz Superdome.  (Photo by Scott Halleran/Getty Images)
Scott Halleran/Getty Images

In case you hadn't heard, David Epstein and George Dohrmann of Sports Illustrated reported on Jan. 29 that Baltimore Ravens linebacker Ray Lewis is among those linked to the use of deer antler velvet spray—a compound that contains the banned substance IGF-1.

The SI report claims that Lewis requested items from the controversial company S.W.A.T.S.—Sports with Alternatives to Steroids—to speed his recovery from the surgical repair of his complete triceps tendon rupture.

As discussed by B/R lead writer Will Carroll, IGF-1—whose full scientific name is insulin-like growth factor 1—is closely linked to human growth hormone (HGH). Under normal circumstances, HGH, produced within the brain by the pituitary gland, travels through the blood stream to liver and causes the liver to secrete IGF-1.

Among its many actions, IGF-1 stimulates the body's natural healing processes. Additional, outside IGF-1 use—called "exogenous" use—could therefore theoretically speed up those processes and allow Lewis to return to the field sooner than expected.

So is that what happened? Like so many other stories involving performance-enhancing drugs (PEDs), it will probably never be absolutely clear.

Lewis has already announced his plans to retire after the Super Bowl, and he has vehemently denied the accusations against him. That suggests he would appeal any investigatory proceedings—something that would effectively eliminate any chances he could be found guilty before his final NFL game this Sunday.

That said, Lewis returned to the field incredibly quickly—much more quickly than anyone could have anticipated. Could it have been the deer antler spray? Maybe.

Or maybe it was the platelet-rich plasma (PRP).

Michael Silver of Yahoo! Sports reported in November that Lewis used a form of PRP to aggressively treat his recovering triceps during the weeks following its surgical repair.

Also, according to Eric Pincus of the Los Angeles Times, Los Angeles Lakers center Dwight Howard will undergo PRP treatment, as well. Howard has been battling a torn labrum in his right shoulder that he has re-aggravated several times this season.

As its name suggests, PRP consists of plasma—the pale yellow, watery part of blood that carries proteins and nutrients—with high concentrations of platelets—the small cells most known for helping stop bleeding. In many cases, PRP treatment consists of removing the patient's own blood, concentrating it with a centrifuge—a rapidly spinning instrument used to separate blood into its different components—extracting the platelets and injecting them in and around the injured or healing tissue.

How is it theorized to work? Dr. Mark Niedfeldt, team physician for the Milwaukee Brewers and associate clinical professor of family and community medicine at the Medical College of Wisconsin, explains:

Platelet Rich Plasma contains a more concentrated amount of platelets than whole blood. These platelets contain powerful growth factors and are fully functioning, complex coordinators of coagulation, inflammation and repair. Concentrated growth factors within the PRP work to initiate a healing response within the injured tissue.

In other words, platelets carry within them a number of proteins that stimulate cell growth and regeneration. Upon their release, the normal healing process of the body is revved up.

One of those proteins—and this might be the ultimate irony of this entire story—is IGF-1, the very same protein whose presence in deer antler spray started this whole fiasco.

So does PRP actually work? Dr. Niedfeldt continued:

In athletics, most of the attention (with PRP) is paid to tendon and ligament healing. Studies have been a bit mixed, with some showing good results in treatment of lateral epicondylitis—tennis elbow—and plantar fasciitis, but some showing no significant difference between PRP and sham injections.

Other uses for PRP include using it in a more acute setting of muscle strain and augmentation of surgical repairs. It is too early to make a definitive statement on using it for acute muscle strains, but a couple of small studies have shown potentially quicker return to play. PRP has been studied in augmentation of ACL grafts, Achilles tendon repairs, and rotator cuff repairs. Results have been mixed.

Basically, the jury is still out, but in some cases, PRP definitely sounds promising. Dr. Jon Rubenstein—a sports medicine and PRP specialist located in South Florida—related the following success stories:

  • 32-year-old professional MMA fighter with less than half of normal neck range of motion (ROM) owing to spinal injury and neck surgeries who recovered nearly all of his ROM following PRP therapy
  • 34-year-old professional MMA fighter who saw a three millimeter hip labrum tear—an injury that is notoriously stubborn to heal—fully resolve following three PRP injections, physical therapy and training

Due to its reported successes, PRP remains a subject of discussion in various anti-doping circles. In 2009, Travis Tygart—CEO of the United States Anti-Doping Agency (USADA)—said (h/t Mike Bresnahan and Broderick Turner of the Los Angeles Times):

If you get PRP with HGH added to it, yeah, no question [...] that is prohibited. As the [PRP] technique started gaining some traction over the last two or three years in athlete circles and among doctors that treat athletes, those doing it without HGH and IGF-1 weren't seeing the same benefits. There wasn't enough evidence that PRP by itself was proving enough enhancement to make it unfair.

Clearly, the debate rages on, and the slope between HGH, IGF-1 and PRP is definitely a slippery one. Deer antler spray is banned due to it containing IGF-1, but PRP is not and remains legal for use throughout the sporting world.

Whether or not those somewhat paradoxical regulations are based off the nuance that the platelets come from the athlete himself versus an outside source is another debate altogether, but one main difference lies in how they are introduced to the injured tissue or muscle.

Exogenous HGH or IGF-1 use allows the compound in question to spread throughout the entire body in addition to the injured tissue, whereas PRP treatment consists of localized injections into healing or injured tissue only by professionally trained specialist physicians.

In Lewis' case, that localized injection was to his triceps tendon.

Tendons—like cartilage and ligaments—are relatively devoid of blood supply when compared to tissues such as the skin or muscle bodies. For that reason, they tend to heal much more slowly or not at all—the reason that 49er Justin Smith's partially torn triceps tendon remains injured and will require surgical repair after the Super Bowl.

The same logic applies to Dwight Howard's injury, as shoulder labrums are cups of cartilage that help stabilize the shoulder joint. They do so by providing extra support to the humerus—the bone of the upper arm—as it inserts into the glenoid—part of the shoulder blade. However, as cartilage, they also sport lower blood supplies.

That relative lack of blood supply to cartilage and tendons implies a lack of platelets, as well, and PRP serves as a method to introduce those missing platelets to the injury.

Evidence for or against the effectiveness of PRP will continue to mount, and agencies such as the USADA will likely continuously review and re-review that evidence and adjust policy as they see fit. If such an adjustment will ever be made remains unclear.

What is clear, however, is the fact that Ray Lewis returned from a complete tendon rupture in less than three months—something that would have been laughed off as fantasy immediately following his surgery—and as a result, Lewis will finish his career with a Super Bowl appearance. At the same time, Dwight Howard's injury just won't go away, and perhaps PRP will do the trick.

Yet while PRP treatment remains legal, deer antler spray is not, and the polarizing Lewis certainly would much rather have ended his story without the controversy that has plagued him over the past few days.

Yet when you have to allegedly call a company to ask how, exactly, to take the medicine they provided, you must be willing to accept whatever consequences might be looming on the horizon.

Dave Siebert is a medical/injury Featured Columnist for Bleacher Report who will graduate from medical school in June and plans to specialize in both Family Medicine and Primary Care (non-operative) Sports Medicine. Except for quotations—which were obtained firsthand unless otherwise noted—all above information and opinion is based on his own analysis and knowledge.