Lions prop Andrew Sheridan is out of the World Cup due to a shoulder injury.
The 2005 and 2009 Test Lion suffered the latest in a long line of setbacks in England's opening game against Argentina at the weekend and will head home for further treatment, subject to the approval of the Rugby World Cup Ltd medical team.
Sheridan had only returned to the England side for the final World Cup warm up against Ireland at the end of August after having surgery on his right shoulder earlier in the year.
The giant loosehead missed the majority of the RBS 6 Nations campaign with a back pain and then a calf strain and has now seen his World Cup dream ended by yet another problem with his left shoulder.
Sheridan has already had surgery on his left shoulder twice in his professional career but it is as yet unclear whether he will require a third operation there when he arrives back in England.
"I have to wait till I get back home and see the surgeon - I am quite well acquainted with him now," said Sheridan.
"He will give me some good advice and see if I need an operation."
England are undecided as to who will replace Sheridan in their 30-man squad, with tournament rules not forcing team manager Martin Johnson to call up another player in Sheridan's prop position.
Johnson could therefore turn to Sale flanker Hendre Fourie to cover the openside flanker role or he could even throw an international lifeline to Lions centre Riki Flutey who was the biggest name omission from the final squad.
If he does decide to keep his contingent of props at five, Paul Doran Jones or Tim Payne look most likely to be called up having been in Johnson's original 45-man training squad.
"It's really sad for Sheri," said England team manager Martin Johnson.
"He has been unlucky with injuries and we wish him all the best for his recovery.
"We brought five props so we have options there and we can bring another player out but we will decide what to do about that in due course."