With the Six Nations in full swing, England are unfortunately without their number 10 and skipper following two ankle injuries in just a few months. Over the past few months, the England captain has had an unlucky run of injuries. In November, he limped off in the final quarter after sustaining an ankle injury vs Australia. In January, it was reported that he had returned to training and had be selected to captain England in their 2022 Six Nations campaign. Unfortunately this is where the England skippers preparation for the six nations ended. According to the Saracens website, he sustained a similar injury to his right ankle this time and underwent surgery towards the end of January. As with most professional athletes, injury information is hard to come by and the rehab is kept quiet behind closed doors. There has been no official statement from the player or the club over what injury he sustained, so all the information we have available is the replay (match highlights available on Youtube). However, in true rugby style the video shows a pile of bodies competing for the ball on the ground, with a slowly emerging injured Owen Farrell at the bottom. Therefore, we will hypothesis what injury the flyhalf had. Of course, I cannot comment on this new injury as there is no video evidence or information available regarding this injury.

Reviewing footage of injuries is an important feature in the medical management of patients. Being able to see the mechanic of issues can aid diagnosis and can be used to formulate a ‘prehab’ programme to strengthen specific structures if the injury is common in that specific sporting discipline. From the footage, we can see the player diving to catch the ball with one of the opposition players landing on the outside of the leg; causing direct impact to the ankle and the Fibula. I would also suggest there is a large amount of rotation occurring at the ankle joint as he twists for the ball. From the medical assessment, we see the doctor and physio squeezing the lower leg, causing significant pain to the player. Assessment of the ankle looks fairly pain-free. We also see the player walk off, without the need for a stretcher. Therefore we will hypothesise the injury to be a Fibula fracture. The club's official statement was that the player had had surgery on the ankle with a prognosis of 8-10 weeks. Fibula fractures can be treated both surgically and non-surgically dependent on the type of fracture and structures involved


The good news is that Owen Farrell had progressed with his recovery as we would have expected. He had returned to squad training within weeks of the injury and was on course to return to rugby within his initial prognosis time frame.



I will start with an unusual ‘rehab’ intervention as it can go through all the stages – psychology! As with any sport, return from injury is a tough affair. Therefore the psychological impact of injury needs to be considered. Setting a realistic prognosis as early as possible to prepare the player for their journey can help. Goal setting/milestones can be helpful for the patient/athlete so they can see their progression. Integration into the team setting should also be a consideration e.g. The England captain should be able to join in with the entire upper limb strength training programme. This is an area that is perhaps neglected somewhat at amateur level sport however most professional athletes have access to psychological support. Physiotherapists certainly have a role to play here though as often we will be the ones doing most of the rehab and seeing the player regularly. It also worth pointing out that during this stage of rehab, he will be completing it with his club, not at international level!

If you think he’ll be resting up for the first few days, you’d be mistaken. Like all professional athletes, they need to remain top of their game, therefore changing their training immediately after injury is necessary. They need to maintain their cardiovascular function, their strength, coordination etc. With this lower limb injury, upper body gym training will still continue as normal. There may be some adaptions for standing exercises however he can continue training nonetheless.

Postoperatively, the first few days will focus on reducing swelling, pain and maintaining ankle range of motion. Simple movements of the ankle and knee, regular elevation and analgesia will all occur at this stage. The benefit of being an elite athlete is having access to a hydrotherapy pool. Once the wound is closed and healing well, it’s likely he’ll be in the pool completely with a combination of ankle mobility, strengthening and cardiovascular exercise. Another potentially useful piece of equipment, in this case, would be an anti-gravity or water treadmill that can be used in the early rehab stage. This allows the player to walk/run with reduced weight on the ankle and this can easily be progressed from 10% to 20% etc. another key aim of both hydrotherapy and anti-gravity treadmill training is to normalize the walking pattern (gait). As much as possible we want to avoid limping and altered biomechanics to minimize the risk of mechanical pains in other joints.

We can almost look at this as a building phase. We are trying to build the strength back up, improve mobility and coordination. And of course, avoiding significant pain during our rehab. This can be a lengthy phase of rehab dependent on the limitation that the patient presents with. In the England captain’s case, I would assume he progressed fairly well and had hopefully maintained a lot of his strength and power were given how quickly he had his surgery and how quick his prognosis was. If we were to see a patient with a severe lower limb injury that required weeks of non-weight bearing and bracing, the muscle wastage would be much more severe therefore this ‘building’ phase would be significantly longer.

Return to full weight-bearing – if weight bearing is restricted. As emphasized in the previous stage, we want to ensure a normal gait patient before we progress to running.

Return to weight-bearing strength training.

Balance, proprioception and coordination training.

Return to running – phased return via a return to running programme and impact programme. As strength building and control in the ankle return, the rehab plan will start to become more rugby focus and more functional.

Start progression into sprinting and including direction changes.

Sports specific drill e.g direct changes, high ball catching and landing.

Then in this stage of recovery, we will start to see integration into team training on a phased return.

Contact training - with rugby being such a physical sport, he will like to return to contact training on a 1 to 1 with coaches/physio’s/S&C – utilizing tackle bags and shields before progressing in rucking and mauling

Strength testing, CV testing, speed, agility will all start to occur at the end of this stage to ensure the play is safe to return to play and full training


The final stage of rehab will require the player to have a full range in the ankle, full strength, full power, full speed. The England captain will be in full team training by this stage including contact training. We can sometimes see this stage of rehab when we watch sports live, specifically team sports. We see players return as substitutes, playing 15-20mins whilst their full match fitness returns. Over the final few weeks of rehab, we see the play return to full matches and hopefully, they return to the starting lineup.

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