England have called up Bath lock Charlie Ewels as injury cover for Maro Itoje, who is now in doubt for the Guinness Six Nationsmatch against Italy on Saturday following an apparent setback in his recovery from a medial ligament injury.

The injury occurred when the England squad were taking part in an attacking passing exercise at their Pennyhill Park training base near to the posts, with Eddie Jones, the head coach, acting as defender. As Itoje went to step around Jones, the lock noticeably grimaced after stepping off his right leg before going to ground.

The 24-year-old then limped away and was seen talking to physios on the sidelines before leaving the training field.

Before England’s latest squad update was released on Tuesday evening, Scott Wisemantel, the attack coach, played down the seriousness of Itoje’s withdrawal, describing the incident only as a “minor tweak”. The decision to call up Ewels as injury cover, however, suggests that Itoje’s participation against Italy is now in real doubt.

Itoje originally damaged ligaments in his right knee in England’s opening Six Nations victory over Ireland last month, forcing him to miss the past two fixtures, against France and Wales.

The initial diagnosis on Itoje’s injury in Dublin was that he would be out for two to four weeks, making him on track this week to face the Azzurri.

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Wisemantel dismissed the suggestion that Itoje had been rushed back into action too soon, or that England’s training regime had anything to do with his setback.

“I don’t think so, no. That’s not the case. It’s quite minor. Our medical staff have done a great job. You can take that doom-and-gloom approach, but the reality is that the medical staff have worked hard and done a brilliant job,” Wisemantel explained.

“When you diagnose someone, you usually go long-term, and then peel it back so it makes you look good. It’s like that with most clubs in the world.

“More often than not, you have a player coming back a week or two early. The medics in sporting teams now are very good at what they do. But you also think the worst, and then peel it back from there.

“Sometimes players do come back too early but that’s not the case with Maro, he’s good to go. It is a genuinely tough programme. A hard programme, but it’s challenging. When I say it’s tough, I don’t mean in regard to it being long. It’s short and intense, which is Test match rugby, intense blocks under pressure, and that’s it.

“A lot of other nations train the same way. Before the Wales Test, [Warren] Gatland was talking about how intense and full-on their training was. It’s exactly the same.”

Itoje fell during a routine passing drill credit: Getty Images Europe

Jones has retained 27 players including Ewels ahead of Saturday’s game at Twickenham, with uncapped Gloucester wing Ollie Thorley staying with the squad as injury cover for Jack Nowell.

Joe Launchbury and Courtney Lawes have been the second-row pairing in the past two games, before Lawes suffered a calf injury in the defeat in Cardiff that has ruled him out of the rest of the Six Nations.

Launchbury and George Kruis were the remaining locks named in the latest 31-man training squad before Ewels was called up on Tuesday, with back-row Brad Shields also offering second-row cover.

Ben Earl, Alec Hepburn, Chris Robshaw, Harry Williams and Jonathan Joseph have all been released back to their clubs.