Pedestrian Struck by a Turning Car: Spine, Hip and Head Injuries, an Integrated Chiropractic and Medical Case

Who treated the patient

Dr. Alexander David Jimenez, DC, APRN, FNP-BC, led and oversaw this case from the first visit to the last. He holds two licenses: doctor of chiropractic and board-certified family nurse practitioner. That combination matters in a case like this one. A doctor of chiropractic is trained to examine and treat the joints, muscles, and nerves of the spine and limbs to find which segments are not moving properly and to restore that movement with manipulation, soft-tissue work, and rehabilitation. A family nurse practitioner is trained to take a medical history, examine every body system, order and interpret diagnostic tests, prescribe medication, recognize warning signs that need a specialist, and coordinate care with physicians. When one person carries both sets of training, the musculoskeletal and the medical questions are answered in the same room, on the same day, by someone who knows the whole case. You can read more about this dual role on the page describing board-certified nurse practitioner care with Dr. Alex Jimenez and on the page explaining why the clinical team works the way it does.

Dr. Jimenez works within a multidisciplinary practice. The team includes co-treating chiropractors, Dr. Charles Karam, DC, Dr. Christopher Valtierra, DC, and Dr. Alexander I. Jimenez, DC, who provide care under his oversight when a patient’s schedule or needs call for it, as well as medical providers, including a board-certified internal medicine physician who serves as the practice’s medical director, and clinical staff trained in rehabilitation, massage, body composition testing, and foot scanning. The practice offers the medical services of a family practice and internal medicine office alongside chiropractic, rehabilitation, nutrition, naturopathic, and acupuncture care. In this case, the patient’s examinations, treatment decisions, re-examinations, final neurological examination, and specialist referral were all carried out by Dr. Alexander David Jimenez, DC, APRN, FNP-BC, with the clinical team delivering the hands-on therapies he prescribed at each visit.

Holistic and allopathic, not one or the other

Many people picture two separate worlds. In one, a chiropractor or holistic practitioner treats the body with hands, movement, and lifestyle and avoids medicine. In the other, a medical office prescribes, orders scans, and refers to specialists and has little time for how a joint moves or how a person sleeps, eats, and works. Our practice deliberately aligns itself with both models at once, and we hold ourselves as different from offices that practice only one.

The holistic side of the model asks, “What is this whole person carrying into recovery?” It looks at movement, posture, foot mechanics, body composition, sleep, work demands, stress, and nutrition, because each of these can speed or slow healing. The allopathic side asks: is there anything here that needs a medical answer? It screens for red flags, decides when imaging is warranted, reviews and manages medication, and recognizes when a neurological finding needs a specialist. In this case both questions were asked at every stage. The patient received hands-on chiropractic and soft-tissue care for his injured spine and hip, and he also received a full medical and neurological screening at discharge, which found something that needed a neurologist’s opinion. Neither model alone would have done both.

You can explore this integrated approach on the practice’s sister site, which describes how integrated injury care connects medical, chiropractic and rehabilitation support, and on the main site’s personal injury doctor page.

Why integration matters after a collision

A person struck by a vehicle rarely has only one problem. The same event can sprain spinal ligaments, strain muscles, irritate nerves, jar the brain, and disrupt sleep, mood and work. Each of these can affect the others. Neck and back pain can drive headaches; headaches can disturb sleep; poor sleep lowers pain tolerance; a painful hip changes how a person walks, which loads the back differently. When different problems are handled in different offices that do not talk to each other, important connections are missed. An integrated team sees the connections because it sees the whole patient.

Integration also protects patients. A chiropractor without medical training may treat a neck that is improving and never check reflexes at discharge. A busy medical office may prescribe a pain reliever and never notice that a hip joint is not moving. In this case, a reflex difference found only on a full neurological examination at the end of care changed the plan: instead of simply closing the case, the patient was referred to neurology. That is integration working as it should.

The integrated team’s roles in this case

• Lead clinician (chiropractor and family nurse practitioner): history, examination, diagnosis, treatment plan, chiropractic manipulation, re-examinations, medication review, neurological screening, referral decisions.
• Clinical and rehabilitation staff: cold therapy, mechanical traction, electrical muscle stimulation, therapeutic massage and percussive soft-tissue therapy at each visit, under the lead clinician’s plan.
• Diagnostic technology staff: body composition analysis and the digital foot scan used to assess factors that can slow recovery.
• Outside specialists: a neurologist for the reflex and strength findings at discharge, and a pain-management physician who was discussed mid-course if leg pain did not settle.

How integrated care compares with the usual path

The collision and why the mechanism injures

The patient, a man in his early 20s who worked a physically active service job, was crossing a street in a marked crosswalk on his way to work when a car making a right turn struck him on his right side. He was looking straight ahead and did not see the car coming, so he had no chance to brace. The impact threw him to his right and onto the pavement, and he struck his head. He did not lose consciousness. Police came to the scene, and emergency medical services transported him to a hospital, where he was examined and had X-rays. He was told no bones were broken.

What happens to a pedestrian’s body

A driver or passenger is surrounded by a steel frame, held by a seat belt, and cushioned by airbags and a head restraint. A pedestrian has none of these. All the energy of the striking vehicle is delivered directly to the body at the point of contact, and then a second impact follows when the body hits the ground. In this case there were three distinct loading events:

1. The side impact. The car struck the right side of the body. This pushes the trunk sideways and twists it, stretching the ligaments that hold the vertebrae together on the opposite side and compressing the joints on the struck side. The thoracic (mid-back) and lumbar (low-back) spine take much of this sideways and twisting load.
2. The head acceleration. When the trunk is pushed suddenly sideways, the head lags behind and then whips sideways, loading the neck muscles, ligaments and small facet joints. This is a sideways version of the familiar “whiplash” mechanism. You can read about it on the practice’s whiplash injuries page.
3. The fall and head strike. Falling from standing height onto pavement loads the hip, pelvis and leg that land first and delivers a direct blow to the head. Even without loss of consciousness, a blow to the head can produce headaches, dizziness and other symptoms of a mild brain injury.

The speed of the car was not known, and it does not need to be known to explain the injuries. A turning car moves relatively slowly, but even at low speed it carries far more mass than a person, and the fall onto a hard surface adds its own force. Injury depends as much on the position of the body and the way it lands as on speed.

Why symptoms can build over days and weeks

Right after the collision the patient felt pain in his back, chest, face, head, neck, right shoulder and arm, and left hip, thigh, knee, leg and foot. Over the following days he also noticed numbness and tingling, headaches and tiredness. This pattern, where some areas settle while others become more noticeable, is common after soft-tissue injury. Inflammation peaks in the first days, muscles begin to guard injured joints, and stiffness builds. Nerves irritated by swelling can produce tingling or radiating pain that was not there on the first day. Some patients feel well enough to return to work for a time and then find the pain persists or worsens with activity. The patient in this case described his symptoms as improving in daily function but with the same level of pain when he first came to the practice, about a month after the collision.

A delay between a collision and specialized care does not mean the injury is minor or unrelated. In this case the patient had emergency care on the day of the collision, used pain medication in the following weeks, and continued to have symptoms when he arrived. The research on neck injuries after collisions shows that a significant share of people continue to have symptoms well beyond the first weeks⁷.

Understanding the injury

To follow the rest of this case it helps to understand the structures that were injured and how they heal. The terms below appear throughout, and a full glossary is at the end of the page.

The anatomy involved

The spine is a stack of 24 movable vertebrae: seven in the neck (cervical), twelve in the mid-back (thoracic, where the ribs attach) and five in the low back (lumbar), resting on the sacrum and pelvis. Each pair of vertebrae is joined at the front by a disc and at the back by two small facet joints. Strong ligaments run along the front and back of the spine and between each pair of vertebrae, and layers of muscle on each side move and protect it. Spinal nerves leave the spinal canal between each pair of vertebrae and travel to the arms, chest, abdomen and legs.

The hip is a ball-and-socket joint between the head of the thigh bone and the pelvis. It is wrapped in a thick capsule reinforced by ligaments, and surrounded by powerful muscles: the gluteal muscles behind, the hip flexors in front, the adductors on the inside, and the hamstrings and quadriceps that cross the hip and knee.

The sciatic nerve is the largest nerve in the body. It is formed from the lower lumbar and upper sacral nerve roots, runs through the buttock and down the back of the thigh, and branches to supply the back of the leg, the calf and the foot. Irritation anywhere along its path, from the nerve roots in the low back to the buttock, can produce pain that radiates down the leg, often with tingling or numbness. This is called sciatica.

Sprains, strains and their grades

A sprain is an injury to a ligament or joint capsule, the tough connective tissue that holds bones together. A strain is an injury to a muscle or tendon. Both are graded by severity:

• Mild (grade I): fibers are stretched with microscopic tearing; the joint remains stable; pain and stiffness last days to a few weeks.
• Moderate (grade II): partial tearing; more pain, swelling, guarding and loss of motion; recovery takes weeks to months.
• Severe (grade III): extensive tearing or rupture; marked pain, loss of function and sometimes instability; recovery can take months and may leave lasting effects.

In this case, the patient was diagnosed with sprains of the thoracic and lumbar spine, and with a severe sprain and strain of the left hip: injury to both the ligaments and capsule of the hip joint and the muscles and tendons around it. The severity was judged from the force of the fall, the immediate onset of hip pain, the restriction and muscle guarding found at every visit, and the two-month course to resolution.

What “segmental dysfunction” means

After an injury, individual spinal segments and extremity joints often stop moving through their normal range. Muscles around them tighten to protect them, and the joint becomes stiff and painful. Chiropractors find these restricted segments by feeling the motion of each joint, a technique called motion palpation, and record them as segmental and somatic dysfunction. Restoring motion to these segments with manipulation is one of the main goals of chiropractic care. In this case, restriction was found at every level of the thoracic and lumbar spine and at the left hip, knee, ankle and foot, and the neck was treated at every visit as well.

The phases of soft-tissue healing

Injured ligaments, muscles and tendons heal in overlapping phases, and good care is timed to match them:

1. Inflammation (first days to about a week). Blood flow increases, swelling develops, and the body clears damaged tissue. Pain and guarding are at their highest. Care focuses on controlling pain and swelling and protecting the area while keeping gentle motion.
2. Repair (about one to six weeks). The body lays down new collagen to bridge the injury. This early scar tissue is weak and disorganized. Care focuses on restoring motion so the new tissue forms along normal lines of stress, and on reducing muscle spasm.
3. Remodeling (six weeks to a year or more). The new tissue matures, strengthens and reorganizes. Even after pain settles, healed ligament is usually not as strong as the original tissue. Care focuses on strength, endurance, posture and gradual return to full activity.

The patient in this case began care in the repair phase, about a month after the collision, and was discharged from active care roughly three months after it, in early remodeling. That timing explains why his recovery continued after discharge and why flare-ups with heavy activity remained possible.

Why pain can outlast the injury

Pain is produced by the nervous system, not by tissue alone. After an injury the nerves in and around the injured area become more sensitive, and the spinal cord and brain can turn up the volume on pain signals. This process, called sensitization, protects an injured area in the short term but can make pain linger, spread, or flare with ordinary activities. Poor sleep, stress and inactivity can amplify it; graded activity, good sleep, reassurance and manual therapy can calm it. Understanding sensitization helps patients see that a flare-up after a long shift does not necessarily mean new damage.

Headache and dizziness after a head strike

The patient struck his head on the pavement. He did not lose consciousness, but he reported headaches from the start, and about six weeks after the collision he reported headaches with dizziness. Headache that begins within a week of a head or neck injury is called post-traumatic headache. It is the most common symptom after a mild head injury, and it can persist for months; a large review found persistent post-traumatic headache in close to half of adults after traumatic brain injury, at similar rates across mild and more severe injuries¹⁰. These headaches can resemble migraine or tension-type headache¹⁵. Neck injury contributes as well: irritated neck joints and tight neck muscles can refer pain into the head, and headache and neck pain at the emergency department are among the risk factors for persistent symptoms after a mild head injury¹¹.

Why the neck was involved

The patient was struck from the side, not from behind, yet his neck was part of his worst pain area at intake. This is common in side impacts. When the trunk is pushed suddenly sideways, the head, which weighs about as much as a bowling ball, initially stays where it was and then is pulled sideways by the neck. The muscles on one side are stretched quickly while they are trying to contract, and the small facet joints on the other side are compressed. The neck then rebounds, and finally the head may strike the ground. Each phase loads different tissues. Sideways movement is also less familiar to the neck than bending forward and back, and the muscles are less prepared to resist it.

In this patient the neck was treated with manipulation at every visit. He reported upper back and neck pain again in his second week of care, and at the final examination his neck still did not bend backward or turn to the left as far as it should, and the muscles on the right side of the neck and upper shoulder remained tight. These residual findings fit a sideways neck injury and are part of the reason the neurology referral asked about the neck.

How a low-back sprain irritates the sciatic nerve

The patient’s leg pain followed the course of the sciatic nerve: down the back of the thigh, into the calf and to the sole of the foot, with additional pain at the front of the thigh, shin and top of the foot, and with numbness and tingling. How does a sprain in the back produce pain in the foot?

The nerve roots that form the sciatic nerve leave the spine through small openings in the low back, right next to the facet joints and discs. When the ligaments and joints of the low back are sprained, the tissues around these openings become inflamed and swollen, and the chemicals released by inflammation can irritate the nerve roots directly. Muscle spasm in the low back and buttock can add pressure along the nerve’s path. The result is pain that the brain perceives in the leg, where the nerve travels, rather than in the back where the irritation is. This explains why his leg pain improved as his low-back motion improved, and why it flared with long periods of standing and weight bearing, which load the low back and narrow those openings slightly.

Sciatic pain from inflammation usually improves over weeks to months with conservative care. If it persists, worsens, or is accompanied by weakness or reflex loss that fits a single nerve root, imaging of the low back may be needed to look for a disc injury pressing on the nerve, which is why lumbar imaging remained an option in his long-term plan.

Why being unbraced matters

The patient was looking straight ahead and did not see the car turning toward him. People who see an impact coming tense their muscles in the fraction of a second before it, which stiffens the spine and reduces the motion between vertebrae. People who are caught by surprise have relaxed muscles, so the force produces larger, faster movements between segments before the muscles react, and those larger movements stretch ligaments further. Being struck unexpectedly from the side, as he was, is one of the circumstances in which soft-tissue injury to the spine is most likely.

Factors in this patient that affect recovery

Two features of this patient’s body, present before the collision, were assessed at the start because they can influence recovery. They did not cause his injuries, but they shaped how his care was planned.

• Body composition. Body composition testing showed a high percentage of body fat and a high visceral fat level. Large reviews have linked obesity to a higher rate of low back pain, more care-seeking for it, and more chronic low back pain¹², and to a higher risk of radiating leg pain and sciatica¹³. Extra load on the spine and hips, and the low-grade inflammation that accompanies excess visceral fat, are thought to play a part. You can read more about how the practice uses InBody 770 body composition and body water analysis and what the body composition terms mean.
• Foot mechanics. A digital foot scan showed severe pronation, meaning the arches collapse and the feet roll inward when standing. Pronation changes how force travels up through the knees, hips and low back with every step. For a patient with an injured left hip and left-leg pain who stands for long shifts at work, this matters. Read more about custom orthotics in chiropractic treatment.

Presentation at the first visit

The patient came to the practice about a month after the collision. He completed an online intake questionnaire and a handwritten pain form with a body diagram, and he was examined by Dr. Jimenez the same day.

History

He described his worst area as the center of his neck and his upper and middle back, which he rated 8 out of 10 on the questionnaire. On the handwritten form the same day he rated his back pain 6 out of 10, noting that it “goes up” with movement, and his left leg pain 6 out of 10. In the examination room he described pain in the low back and the mid and upper back, with tightness in the hip and low back and shooting pain down the left leg. The pain spread to the front and back of the left thigh, the front and back of the left lower leg, and the top and bottom of the left foot. He described the pain as aching, stabbing and throbbing, intolerable at times, with stiffness. It was worse with bending, lifting and carrying 10 to 20 pounds or more, walking and running, and better with rest, stretching and his pain medication. He also had a few headaches since the collision, numbness and tingling, and tiredness. Lifting was the activity he found hardest, and his goal was simple: to be able to lift without limits again.

He had never had episodes like this before. He reported no prior illnesses, surgeries, allergies or accidents, and no earlier neck, back or leg care. His only medication was the pain reliever he had been using since the collision.

Examination

The examination separated what he reported from what the examiner could see and feel:

• Spinal restriction: every level of the thoracic and lumbar spine, from the top of the mid-back to the bottom of the low back, was restricted on motion palpation.
• Extremity restriction: the left hip, knee, ankle and foot were restricted.
• Tenderness: from the base of the neck through the sacrum, and over the left upper leg, lower leg, ankle, foot and sole.
• Muscle spasm: increased tone (hypertonicity) in both trapezius muscles, the muscles along the whole thoracic and lumbar spine, the left sacroiliac region, the left buttock and hip, and the front and back of the left thigh, knee, shin, calf, ankle and foot.
• Range of motion: movement of the low back in every direction, and bending forward and backward through the mid-back, was severely reduced and painful. He showed pain when bending on the table.
• Vital signs: blood pressure was mildly elevated and pulse slightly fast, findings that can accompany pain.

Baseline measures

Two baseline tests were performed in the first two visits. Body composition analysis measured weight, fat, muscle and body water, including the ratio of fluid outside the cells to total body water, which can rise with inflammation and swelling. A digital laser foot scan measured how his arches and feet loaded when standing. Both are described in more detail below. Together with the pain ratings and the examination, these gave a baseline against which progress could be measured.

Dr. Jimenez assessed the patient as in fair health, expected to make fair progress with some residual symptoms, and likely to need longer than an uncomplicated case to recover. No reason was found not to begin gentle, conservative chiropractic care, and treatment three times a week for four weeks was recommended.

Triage and medical work-up

Before any hands-on treatment begins after a collision, the medical side of an integrated practice asks whether anything needs a different kind of care first. This step is called triage.

Screening for red flags

Red flags are findings that suggest a serious problem such as a fracture, spinal cord or nerve compression, infection, a bleed in the head, or an injury to an internal organ. They include severe or worsening headache, repeated vomiting, confusion or drowsiness, new weakness or loss of sensation, loss of bladder or bowel control, unexplained fever or weight loss, and pain that is constant and unrelieved by any position. At the first visit the patient had none of these. He had been examined at a hospital the day of the collision, and his X-rays showed no fracture. He was alert, walking, and able to describe his symptoms clearly. His headaches were occasional. That allowed conservative care to begin, with the understanding that red flags would be watched for at every visit.

Deciding about imaging

Imaging is a tool, not a routine. National radiology criteria recommend against routine MRI for back pain that is improving with conservative care, and in favor of MRI when there are neurological signs, red flags, or radiating symptoms that persist despite treatment⁶. The X-rays taken at the hospital had ruled out fracture. At the start of care the patient had radiating leg pain but no measured weakness or reflex change, so the plan was to treat and watch closely. That decision was revisited at the end of care, when the final neurological examination found a reflex difference and mild weakness, and the referral to neurology included a request to consider MRI of the neck.

It is also worth knowing that imaging findings must be read in context. Disc bulges and other “degenerative” findings are common in people of all ages who have no pain at all⁸, so an MRI is most useful when it is ordered to answer a specific clinical question, as it would be here.

Medical evaluation and medication

The patient was using a pain reliever after the collision. As a nurse practitioner, Dr. Jimenez reviewed his medication use at intake. The goal of the integrated plan was to reduce his reliance on medication by treating the source of the pain, and over the following weeks his pain ratings fell to the point where medication was no longer a focus of his visits. Had his pain not responded, short courses of medication during flare-ups were available within the practice, which is one of the advantages of having medical and chiropractic care under one roof.

Whole-person screening

Beyond the injured areas, the work-up looked at the factors that shape recovery: body composition, foot mechanics, sleep, work demands and stress. The patient worked long, physically demanding shifts on his feet. During care he reported a night of poor sleep and, on one visit, stomach pain that had not gone away, which was noted for follow-up. Factors like these are often overlooked in a single-discipline practice, but they matter: a patient who stands for twelve hours on pronated feet with an injured hip will have a different recovery from one who sits at a desk.

Outcome measures

Progress was tracked in four ways:

• Pain ratings for the back and the left leg at almost every visit, on a 0 to 10 scale.
• Range of motion of the thoracic and lumbar spine at every visit, graded from severely reduced to normal, and measured in degrees for the neck at the final examination.
• Function, particularly his ability to bend and lift 10 to 20 pounds, reviewed at each formal re-examination.
• Neurological status, including strength, reflexes, sensation, balance and coordination, at the final examination.

Treatment plan

The patient received multimodal care: several treatments combined at each visit, each with a specific purpose, delivered in phases that changed as he improved. This is the approach recommended by clinical practice guidelines for neck pain and whiplash-associated disorders¹ and for low back pain^2,3, which favor manual therapy, soft-tissue therapy and exercise within a coordinated program over any single passive treatment. In total he attended 25 visits over about eight and a half weeks.

The treatments used at each visit are explained below: what each one is, why this patient needed it, and what the research shows.

Chiropractic spinal manipulation

What it is. Spinal manipulation, often called an adjustment, is a controlled, quick, low-amplitude movement applied to a specific spinal joint to restore its motion. Diversified technique, the method used here, uses the clinician’s hands to position the patient and deliver the movement to the restricted segment. It is often accompanied by a soft popping sound, which is gas being released from the joint fluid and is not a bone “going back into place.” You can read more on the main site’s page about spinal manipulation and adjustments.

Why he needed it. Every level of his thoracic and lumbar spine was restricted at the first visit, and his neck was part of his worst pain area. Manipulation of the neck, mid-back and low back was performed at every visit to restore motion to these segments. As his motion improved from severely reduced to mildly reduced over the first three weeks, his back pain fell in step.

What the evidence shows. A systematic review and meta-analysis in a major medical journal found that spinal manipulation for acute low back pain produces modest, clinically meaningful improvements in pain and function, with mostly minor, short-lived side effects such as temporary soreness⁴. The American College of Physicians recommends spinal manipulation among first-line non-drug treatments for acute and subacute low back pain³, and chiropractic guidelines for both neck and low back pain include manipulation within multimodal care^1,2.

Extremity adjustment

What it is. The same principles of manipulation applied to joints of the limbs: here, the knee, ankle and foot on the left side.

Why he needed it. His left hip, knee, ankle and foot were restricted after the fall, and his left leg carried radiating pain from the first day. Restoring motion in the joints of the leg reduces abnormal loading as he walks and stands, which matters for a patient on his feet for long shifts with severe pronation.

What the evidence shows. Manual therapy of the lower-extremity joints is part of the guideline-based management of foot and heel pain⁹, and chiropractic guidelines endorse manual therapy as part of multimodal care for musculoskeletal pain². The evidence for extremity manipulation is more limited than for the spine, and it is used here as one part of a broader program.

Therapeutic massage and percussive soft-tissue therapy

What it is. Effleurage massage uses long, gliding strokes to relax muscle, improve circulation and reduce tension. Percussive therapy uses a hand-held device delivering rapid pulses to tight muscle. Both were applied for about 15 minutes at each visit, focused on the areas of spasm.

Why he needed it. Muscle spasm was present along the whole spine, both trapezius muscles and the entire left leg at the first visit. Spasm is the body’s way of guarding an injured joint, but it also causes pain and stiffness of its own. He asked for the massage to focus on his leg and back, and when his left shoulder became painful in the second week and the area that hurt most in the third, the soft-tissue work was directed there.

What the evidence shows. A Cochrane review found that massage improves short-term pain and function in low back pain compared with inactive controls⁵. Its benefit is greatest when combined with exercise and education, which is how it was used here.

Intersegmental mechanical traction

What it is. The patient lies on his back on a table with rollers that move slowly up and down the spine, gently flexing and extending each segment in turn for about 15 minutes.

Why he needed it. It provides gentle, repeated motion to every restricted segment between manipulations, helping to loosen stiff joints and relax guarding muscles.

What the evidence shows. Evidence for traction alone is limited. Guidelines treat it as an adjunct within multimodal care rather than a stand-alone treatment², and it was used that way here.

Electrical muscle stimulation

What it is. Low-voltage electrical current delivered through pads on the skin, which produces a tingling sensation and helps relax muscle and reduce pain signals.

Why he needed it. To reduce muscle spasm and pain in the spine and left leg, particularly in the first weeks when pain was highest.

What the evidence shows. Electrical stimulation provides short-term pain relief for some patients, but the evidence is mixed, and guidelines describe it as an adjunct rather than a primary treatment¹.

Cold therapy

What it is. A dry cold pack applied for about 15 minutes to the painful areas.

Why he needed it. To ease pain and muscle spasm after treatment and during flare-ups. In one visit the plan specifically noted continuing ice and electrical stimulation as tolerated for muscle tightness.

What the evidence shows. Superficial heat and cold are low-risk options for short-term symptom relief and are listed as adjuncts in guidelines³.

Activity training, home exercise and education

What it is. Instruction in safe bending, lifting and daily activities, and a program of stretches and exercises to do at home.

Why he needed it. Lifting was his most limited activity, and his work required carrying trays and standing for long shifts. Home stretching was reviewed with him early in care, and he was encouraged to stay active rather than rest.

What the evidence shows. Exercise and education are among the most strongly supported treatments for back pain^2,3. For headache and dizziness after a head injury, current international consensus favors early return to light activity over strict rest, and recommends neck and balance (cervicovestibular) rehabilitation when headaches, dizziness or neck pain persist¹⁴.

Foot biomechanical assessment

What it is. A laser scan of the feet while standing, which maps where pressure falls and measures how much the arches collapse and the feet roll inward. The result is reported as a Pronation Stability Index.

Why he needed it. His left leg was injured, his pain radiated into the foot, and he stood for long shifts. The scan showed severe pronation, which changes how the knee, hip and low back are loaded with every step, and custom orthotics were recommended. Identifying this early helps explain why his leg symptoms flared after long work shifts and guides future care.

What the evidence shows. Clinical practice guidelines for foot and heel pain support the assessment of foot mechanics and the use of foot orthoses for appropriate patients⁹. You can see more on the main site’s foot orthotics section.

Body composition analysis

What it is. A bioimpedance test in which a very small, painless electrical signal passes through the body to estimate fat, muscle and water, including the balance between water inside and outside the cells. It takes about a minute.

Why he needed it. His body composition, with a high percentage of body fat and a high visceral fat level, is a recognized factor in back pain and sciatica, and the fluid balance measure can reflect inflammation and swelling. The test was performed at the start and repeated at re-examination as part of assessing recovery and planning care.

What the evidence shows. Obesity is associated with more low back pain and chronic low back pain¹² and with a higher risk of sciatica¹³, which is why measuring it, and addressing it in the long-term plan, is part of whole-person care. Read more on the main site’s BIA testing page.

Re-examinations and the final examination

What it is. Formal re-examinations repeat the history and examination to measure progress and adjust the plan. The final examination added a full neurological examination: muscle strength in every major muscle group, tendon reflexes, sensation by nerve root, balance (Romberg test), walking heel to toe, coordination (finger to nose), pupils and speech.

Why he needed it. Re-examinations allowed the visit frequency to be reduced safely as he improved. The final neurological examination was performed because he still had brief headaches and because a discharge from active care should confirm that nothing is being missed. It found something that changed the plan.

What the evidence shows. Guidelines recommend re-evaluation at intervals to confirm that care is helping and to decide when to reduce or stop it^1,2.

A closer look

This section explains, in more depth, some of the clinical tools and decisions behind the care described above.

What each examination test shows

At the final examination the patient’s strength was full in every muscle group except straightening the left knee, which was slightly weak at 4 out of 5. The knee reflex on the left was brisker than on the right. The wrist reflexes were absent on both sides. When his neck was fully extended, one beat of clonus appeared in both feet, and none in the neutral position. Sensation, balance, heel-to-toe walking, coordination, pupils and speech were all normal. His neck bent backward to only about 50 to 55 degrees and turned left to about 70 degrees, less than to the right, and the muscles on the right side of his neck and upper shoulder were still tight.

No single one of these findings is alarming on its own, and several can occur in healthy people. Together, after a head strike and with persistent headaches, they called for a neurologist’s opinion. That is the kind of judgment that requires the medical training of an integrated provider: the findings were noticed, put in context, and acted on.

The medication approach

Medication can be a useful bridge after an injury, but on its own it does not restore movement or strengthen injured tissue. The integrated approach in this case used medication only as needed for symptom control while the hands-on care and activity did the work of recovery. Because the lead clinician is also a nurse practitioner, medication could be reviewed, adjusted or prescribed within the same visit if pain flared, rather than requiring a separate appointment elsewhere. By the middle of his care the patient’s pain was low enough that medication was no longer a focus. Short courses during future flare-ups remain an option in his long-term plan.

Screening for concussion and post-traumatic headache

A concussion is a mild traumatic brain injury caused by a blow to the head or a sudden jolt of the head. Loss of consciousness is not required. Common symptoms are headache, dizziness, fatigue, difficulty concentrating, sensitivity to light or noise, sleep disturbance and irritability. The patient struck his head, had headaches from the start, reported tiredness at intake, and had dizziness with headaches in his sixth week after the collision. He was asked about headaches and dizziness at many visits: he denied them in weeks 3, 4 and 6 of care and again in week 8, but at the final visit he reported brief headaches lasting a second or two, once or twice a week, at the side, back and front of his head.

Current international consensus recommends that, rather than strict rest, people with concussion symptoms return early to light physical activity, and that those whose headaches, dizziness or neck pain persist receive targeted neck and balance rehabilitation and, where symptoms last more than a month, collaborative care¹⁴. The same consensus notes that blood and imaging biomarkers currently have limited use in diagnosing or tracking recovery. The plan at discharge followed this thinking: continued activity, monitoring of the headaches, and a neurology referral, with further brain-injury evaluation only if specific symptoms arise.

Exercise progression stages

Recovery after a spinal and hip injury moves through stages of exercise. The patient’s home program began with the first and continues into the later ones.

1. Gentle mobility: pain-free movement of the neck, mid-back, low back and hip, such as pelvic tilts, knee-to-chest stretches, gentle trunk rotations and neck turns, done several times a day.
2. Stretching: holding stretches for the hamstrings, hip flexors, buttock and calf, and the upper back and neck, especially after a long shift.
3. Stabilization: exercises that train the deep trunk muscles to hold the spine steady, such as bracing, bridges and bird-dogs.
4. Strengthening: squats, step-ups, hip-abduction exercises and later loaded carries, with special attention to the left quadriceps, which tested slightly weak at discharge.
5. Work conditioning: practicing the lifting, carrying and prolonged standing his job requires, with good technique and supportive footwear or orthotics.

Exercise is one of the most strongly supported treatments for low back pain^2,3, and it is the part of care the patient carries with him after discharge.

The hip injury in detail

Hip injuries are easy to overlook after a collision, because the pain of a hip sprain often spreads into the buttock, groin, thigh and low back and can be mistaken for back pain alone. In this patient the hip was involved from the start: he felt pain in his left hip immediately after the fall, his handwritten pain diagram and history included the hip and thigh, and on examination the left hip was restricted at every visit, with tenderness and muscle guarding around the hip and buttock. Early in care, the treatment focus was explicitly on the hips, and about five weeks into care he still reported a bit of hip pain.

The hip joint is unusually stable, held by a deep socket, a thick capsule and three strong ligaments. When it is injured, it is usually because a large force drives the thigh bone into the socket or twists the leg while the body is falling. A pedestrian thrown sideways onto the pavement lands on the pelvis and upper thigh, exactly the mechanism that strains the capsule and ligaments and the large muscles around the joint. The patient’s diagnosis reflected both tissues: a sprain of the ligaments and capsule, and a strain of the surrounding muscles and tendons, both classified as severe on the basis of the force involved, the immediate onset, the persistent restriction and guarding, and the length of time they took to settle.

A hip injury matters for the rest of the body. When the hip does not move freely, the low back moves more to make up for it, which can aggravate a low-back sprain. When the hip muscles guard, walking and standing change, which loads the knee, calf and foot differently, especially in someone whose feet already roll inward. The patient himself noticed this: in his third week of care he felt he was compensating on one side, and in his seventh week he developed pain on the opposite side, in the right hip and knee, with weight bearing after a long work shift. This chain of compensation is one reason the treatment plan included adjustment of the knee, ankle and foot as well as the spine, and why his long-term plan includes attention to foot mechanics and leg strength.

By the final visit his left hip and buttock pain had resolved, and his hip moved normally on examination. The residual findings were further down the leg and in the nervous system rather than in the hip itself.

Understanding the neurological findings

The most important moment in this case came at the very end, during the final examination. It is worth explaining in plain language what was found and why it led to a referral rather than a simple discharge.

Reflexes. When a doctor taps the tendon below the kneecap, the quadriceps muscle contracts and the leg kicks. This reflex travels from the tendon to the spinal cord at the level of the low back and straight back to the muscle. The brain normally sends signals down the spinal cord that keep this reflex in check. If the nerve root in the low back is irritated, the reflex usually becomes weaker. If something higher up, in the spinal cord of the neck or in the brain, reduces those calming signals, the reflex can become brisker than normal. In this patient the left knee reflex was brisker than the right. That pattern is not what a simple low-back nerve irritation usually produces, which is why it raised a question about the neck and the brain.

Clonus. When the foot is quickly pushed upward, a few rhythmic beats of the calf muscle can follow. One or two beats can be normal, particularly in a tense patient; sustained beats are not. In this patient one beat appeared in both feet only when his neck was fully extended, and none with the neck in neutral. That finding is subtle, but its link to the position of the neck is the reason the referral asked the neurologist to consider an MRI of the cervical spine.

Strength. Muscle strength is graded from 0, no movement, to 5, normal strength against full resistance. Every muscle group the patient was tested in was 5 out of 5, except straightening the left knee, which was 4 out of 5. That is mild weakness, but it was on the same side as the brisk reflex and the leg that had been injured.

What was normal. Just as important, many things were normal: sensation across every skin area supplied by the spinal nerves, balance with the eyes closed, walking heel to toe, coordination of the arms, the pupils, and speech. These normal findings make a serious, urgent problem unlikely, and they helped decide that a planned neurology referral, rather than an emergency evaluation, was the right step.

Why not wait and see? The patient felt nearly recovered. It would have been easy to close his case. But the combination of a head strike, persistent brief headaches, a reflex difference, mild weakness and clonus linked to neck position is not something a careful clinician leaves unexplained. A neurologist can examine these findings in more detail, decide whether imaging or nerve testing is needed, and either reassure the patient or identify something that needs treatment. That is the standard of care, and it is the kind of judgment that an integrated provider with medical training brings to a musculoskeletal case.

Nutrition, sleep and body composition in recovery

Healing tissue needs raw materials and rest. The practice’s integrated model looks beyond the injured joint to the conditions in which the whole body is trying to heal.

Protein and nutrients. Ligaments, tendons and muscles are rebuilt from protein, and the process depends on adequate calories, vitamin C, zinc and other nutrients. Diets heavy in processed foods and sugar can promote low-grade inflammation, while diets rich in vegetables, fruit, lean protein, whole grains, nuts, olive oil and fish are associated with lower inflammatory markers. For a patient whose body composition showed a high percentage of body fat and a high visceral fat level, nutritional guidance is both a recovery tool and a long-term health measure. The practice’s nutrition services, described on the sister site’s nutrition page, support this part of care.

Body composition, not just weight. The scale alone does not distinguish fat from muscle or show where fat is stored. Body composition analysis does. Visceral fat, the fat stored around the internal organs, is metabolically active and linked to inflammation, which is one reason it is relevant to how injured tissue heals and to long-term risks such as high blood pressure and diabetes. Tracking body composition over time lets patients see changes in muscle and fat that the scale may hide. Gradual, sustainable improvement, combined with strengthening, reduces the load on the spine and hips and lowers the risk of future back pain and sciatica^12,13.

Sleep. Deep sleep is when much of the body’s tissue repair happens, and poor sleep increases pain sensitivity the next day. The patient reported a night of poor sleep during his care, which is common after an injury, when pain, stiffness and stress interfere with rest. Simple measures help: a regular bedtime, a dark and cool room, limiting screens before bed, avoiding caffeine late in the day, and supporting the neck and hips with pillows. When headaches or pain regularly disturb sleep, it is worth telling the provider, because sleep problems can prolong recovery after both spinal and head injuries.

Hydration and fluid balance. The body composition test also measures the balance between fluid inside and outside the cells. After an injury, the proportion of fluid outside the cells can rise with inflammation and swelling. Tracking it alongside symptoms gives one more window on how the body is responding to injury and care.

Stress. Being struck by a car is frightening. Many people feel more anxious near traffic afterward, or worry about money, work and the future. Stress raises muscle tension and can amplify pain. Talking about these concerns is part of whole-person care, and when worry, low mood or nightmares persist, referral to a behavioral health professional can make a real difference to physical recovery as well.

Returning to a physically demanding job

The patient worked long shifts on his feet, carrying trays and food. Jobs like his place repeated demands on exactly the structures that were injured: the low back with every bend and carry, the hip and leg with hours of standing and walking, the neck and upper back with carrying loads in front of the body. It is no surprise that his flare-ups in the second half of care followed work shifts.

Returning to this kind of work after an injury is best done in stages. Where possible, shorter shifts at first, with breaks to sit or stretch, allow the body to adapt. Lifting technique matters: keeping trays and loads close to the body, avoiding twisting while carrying, and using both arms. Footwear matters too, particularly for a patient with severe pronation: supportive, cushioned shoes, and custom orthotics where recommended, reduce the load on the knees, hips and back during long periods of standing. Strengthening the legs and trunk through the home program builds the capacity to meet the job’s demands. And a plan for flare-ups, with ice, stretching and, when needed, a supportive visit, keeps a bad day from turning into a setback.

Employers can help as well. Temporary modified duties, such as fewer heavy carries, more frequent breaks or a mix of standing and seated tasks, often allow an injured worker to stay productive while healing. A note from the treating provider describing safe activities and limits can make these conversations easier.

Why care sometimes starts weeks after a collision

The patient first came to the practice about a month after he was struck. This is common. Many people go to the emergency department on the day of the collision, are told that nothing is broken, and are sent home with pain medication and advice to rest. They expect to recover on their own, and some do. Others find that their pain, stiffness and other symptoms continue, or that they cannot return fully to work and daily life. Only then do they seek specialized musculoskeletal care.

A gap between the collision and specialized care does not mean the injuries are minor or unrelated to the collision. What matters is whether symptoms began with the collision and continued, whether other causes have been considered, and whether the examination findings fit the mechanism. In this case the patient had emergency care on the day of the collision, used medication afterward, and still had pain, restricted motion and radiating leg symptoms when he arrived. Research on neck and back injuries after collisions shows that persistent symptoms beyond the first weeks are common⁷. Starting care earlier is generally better, because restoring motion and calming muscle guarding is easier before stiffness and compensation set in, but it is never too late to have an injury properly assessed.

What the evidence can and cannot tell us

Every treatment in this case was chosen with the research in mind, and it is worth being honest about what that research shows. The strongest evidence supports exercise, education and staying active, and moderate evidence supports spinal manipulation and massage, for neck and back pain^1,2,3,4,5. The evidence for passive treatments such as traction, electrical stimulation and cold packs on their own is weaker; they are useful mainly as short-term adjuncts that make it easier to move and exercise, which is how they were used here. For headaches after a head injury, the evidence favors active approaches and targeted rehabilitation over rest¹⁴. For options that may be considered later if pain persists, such as platelet-rich plasma injections, results vary from condition to condition: meta-analyses suggest better longer-term outcomes than steroid injections in some tendon and heel conditions^16,17, but the evidence for other uses is still developing. Good care uses the evidence as a guide, adapts it to the individual patient, and measures whether it is working.

How progress was measured at each re-examination

The patient had two formal re-examinations during care, at about four weeks and about eight weeks, before his final examination. Each one asked the same questions, so the answers could be compared:

• How much does it hurt? Pain ratings for each area, compared with the first visit. At four weeks his back had fallen from 6 to 4 out of 10 and his leg from 6 to 3; at eight weeks both were at 1 to 2 out of 10.
• How well does it move? Range of motion of the mid-back and low back, which had improved from severely reduced at the start to mildly reduced by four weeks.
• What can he do? His ability to bend and lift 10 to 20 pounds, his most limited activity, was reviewed at each re-examination and was improving.
• Are the short-term goals met? At both re-examinations his short-term goals of reducing pain and restoring motion had been met, and his long-term goal of lifting without limits was progressing.
• Should the plan change? Both times, the answer was to continue active care but reduce the number of visits, moving him toward independence.

Body composition was also re-measured at the first re-examination. Using the same measures at fixed points turns a patient’s sense that they are “a bit better” into something that can be tracked, compared and acted on. It also protects patients from too much care: when the measures show steady progress, visits can be reduced with confidence.

What the patient told us

Measures matter, but so does the patient’s own account. Over the course of his care he described therapy as helping in the first week, said he was “much, much better” in the fifth week, said he was feeling much better than when he first came in during the sixth, and in the eighth week said the aches and discomforts from the accident were gone and he felt back to his pre-accident condition. He recalled that in the first days and weeks after the collision, household chores and work had been the hardest things to do, and that he woke up sore. He noticed that his movement was less stiff and restricted after treatment. These words, recorded at the time, are as much a part of the outcome as the numbers on the pain scale, and they are a reminder that the goal of care is to give people back the ordinary activities an injury takes away.

Why documentation matters

Every visit in this case recorded the patient’s own pain ratings, the examiner’s findings, the treatments given and how he responded. That record serves the patient in three ways. It shows whether care is working, so the plan can be changed when it is not. It gives specialists, like the neurologist in this case, the information they need without starting from scratch. And after a collision, when questions arise about what happened and what care was needed, a clear record answers them. Careful documentation is a standard of good care, not paperwork for its own sake.

Course of recovery

The table and graph below summarize the patient’s progress week by week, measured from his first visit. Pain ratings are on a 0 to 10 scale.

The recovery, phase by phase

Weeks 1 to 4: settling the acute injury. The first weeks were the hardest. On the second visit his leg was briefly better, at 3 out of 10, but it rose again to 5 out of 10 by the end of the first week, and his back stayed at 5 to 6 out of 10. In week 2 he reported headaches with dizziness and continued upper back and neck pain, and a new area, his left shoulder, became painful. His spinal motion, however, was steadily improving, from severely reduced to moderately reduced. In week 3 he described a very good weekend with his leg at 2 out of 10, but the next day the leg rose to 5 or 6 out of 10; he felt he had been favoring one side. By the end of week 4 his back was at 4 out of 10, his leg at 3 out of 10, his motion only mildly reduced, and he reported his back had felt good over the weekend. The re-examination that week found him improving, with his short-term goals met and his ability to bend and lift better, and his visit frequency was reduced.

Weeks 5 to 8: consolidating and managing flare-ups. Week 5 brought the best news so far: he described himself as “much, much better,” and by the end of the week he reported no leg pain at all. The pattern of recovery was not a straight line, though. In week 6 his mid-back rose to 5 out of 10 for a visit even as he said he felt much better than when he first came in. In week 7 his leg rose to 4 out of 10, and he described pain with weight bearing after a work shift, including pain on the right side of his hip and knee as he compensated. Each flare settled within one or two visits. By week 8 his upper and mid-back symptoms were tension rather than pain, his back and leg were at 1 out of 10, and he told the team he felt he was back to his pre-accident condition, recalling that household chores and work had been the hardest things in the first weeks.

Week 9: the final examination. Because a full discharge examination had not been planned for the visit when he reported feeling recovered, he returned the following week for a final visit. That examination, described above, found residual neck stiffness and tightness, a reflex difference and mild weakness in the left leg, and brief, infrequent headaches. Rather than simply closing his case, Dr. Jimenez referred him to a neurologist, with a request to consider an MRI of the neck.

Outcome

The two diagrams below show where the patient had pain or symptoms during his care, and how he presented at the final visit. In the front view the patient’s left is on the reader’s right; in the back view his left is on the reader’s left. The diagrams are illustrative and not to scale.

Of the fourteen areas reported during care, nine had resolved by the final visit. Five remained: mild pain in the low back, left knee and left calf at 1 to 2 out of 10; brief headaches; and examination findings at the neck, the right upper shoulder and the left thigh. His pain had fallen from 6 out of 10 to 1 out of 10 in both the back and the leg, his low-back motion was full, and he felt much better. At the same time, the final examination showed that recovery was not complete, and the neurological findings needed a specialist’s evaluation.

What recovery looked like in daily life

Numbers on a pain scale only tell part of the story. At the start of care the patient could not bend and lift without pain, found household chores hard, struggled through work shifts, woke up sore, and had headaches and tingling in his leg. His stated goal was to lift without limits. By the end of active care, bending and lifting had improved, chores and work were manageable, the leg tingling and most of the radiating pain had settled, and his back pain was rated at 1 out of 10, which he described as tension rather than pain.

The flare-ups along the way are also part of the story. They taught him which activities his healing body could tolerate and which needed pacing: a long shift standing on hard floors, a heavy carry, a weekend of unusual activity. Learning to recognize and manage these patterns, with stretching, cold packs, rest breaks and good footwear, is one of the most valuable things a patient takes away from a course of care, because it lets him handle future flares on his own and seek help when a flare does not settle.

Some things were not yet back to normal. Brief headaches still came once or twice a week. His neck did not turn as far to one side as the other, and the muscles of his right upper shoulder were still tight. His left knee was slightly weaker than his right, and its reflex was brisker. None of these stopped him from working or living his life, but together they meant that his recovery was not finished, and that a specialist’s opinion was needed before anyone could say it was.

This balance, real and meaningful improvement alongside honest acknowledgment of what remains, is what a good outcome looks like after a significant injury. It respects both the patient’s progress and the limits of what has been achieved so far, and it keeps the door open to the next step of care.

Final findings and what comes next

At discharge from active care, the plan included:

• Neurology evaluation for the reflex difference, the mild left knee weakness, the clonus with neck extension and the persistent headaches, with consideration of an MRI of the neck.
• A formal re-examination after the neurology evaluation to determine whether he has reached maximum medical improvement, the point at which further meaningful recovery is not expected.
• Supportive care tapering to self-management over the following year for flare-ups, with his home exercise program as the foundation.
• Contingent options if specific problems persist: imaging of the low back, nerve testing, physical therapy for strength, a podiatric evaluation and orthotics for his feet, and a pain-management opinion.

Prognosis

The outlook for the spinal and hip injuries is fair to good. Working in his favor are his youth, the steady fall in his pain, the return of full low-back motion and his own sense of recovery. Working against him are factors linked to longer or recurring symptoms: a high-energy pedestrian injury with a head strike, radiating leg pain at the start, headache and neck pain after a head injury¹¹, a high body-fat percentage^12,13, severe foot pronation, and a job that keeps him on his feet lifting and carrying for long shifts. Research on neck injuries after collisions shows that a meaningful share of people still report symptoms a year later, and that higher early pain and more symptoms predict slower recovery⁷. Post-traumatic headache can also persist for months¹⁰. The neurological findings at discharge are the main open question, and the prognosis will be clearer after the neurology evaluation.

How we process a case like this

When a patient has been injured in a collision, the care itself is only part of what the practice provides. Patients, their families and, when they are represented, their attorneys often need a clear, accurate account of the injury, the care and the outlook. The practice prepares that account from the medical record, with the same integrated perspective used in treatment. The steps are outlined below; you can read more about the practice’s approach on the personal injury expert section of the main site and on the sister site’s page on supporting personal injury cases with integrative injury care.

1. Record compilation and audit

Every page of the record is gathered: intake questionnaires, handwritten pain forms and diagrams, visit notes, examination findings, test reports such as body composition and foot scans, referral notes, and records from other providers such as hospitals and imaging centers. Each source is read in full, including handwritten and scanned pages, because details such as a pain diagram or a past history entry are often found only there. The record is then cross-checked against itself and against the date of injury. Template entries, dictation errors and inconsistencies are identified and corrected in a dated addendum, never by altering the original entries, so the record remains accurate and trustworthy.

2. Causation and mechanism

For each injured region, the practice examines when symptoms began, whether there was any prior history, what objective findings the examination recorded, what imaging showed, and whether the injuries fit the mechanism of the collision. For a pedestrian struck by a vehicle, that means understanding the side impact, the head acceleration and the fall. Alternative explanations are considered openly. The goal is an honest, region-by-region account of what the collision did and did not cause. Read more about how whiplash rehabilitation and the relationship between whiplash, nerve irritation and chiropractic relief are approached in the practice.

3. A visual course of care

Words and tables can be hard to follow, so the practice builds diagrams like the ones in this case study: a body map of every area reported during care, a second map showing what remains at discharge, and a graph of pain ratings at each visit. These visuals show at a glance where the injury was, how it changed, and where it stands.

4. Future care planning

Based on the final examination and the patient’s risk factors, the practice outlines the care the patient is expected to need, such as supportive visits, re-examination and specialist consultations, and separately the care that would be needed only if specific problems arise, such as imaging, nerve testing or injections. Each item is tied to the patient’s own findings and to clinical guidelines, so it is clear why it is recommended.

5. Medical and chiropractic perspectives in one report

Because the lead clinician is both a chiropractor and a nurse practitioner, the report brings both perspectives together: the joint and muscle findings that guided hands-on care, and the medical and neurological findings that guided referrals and medication decisions. Diagnoses are explained in plain language, with what supports each one in the record and why it matters. The result is a single, coherent picture rather than two partial ones.

Questions patients ask

A practical guide for patients

If you have been struck by a vehicle as a pedestrian or injured in any collision, the following guidance, drawn from this case and from the clinical guidelines it followed, can help you recover. It is general information and does not replace an evaluation by your own provider.

The first days

• Get evaluated, even if you feel mostly fine. Tell the provider about every area that hurts and about any head strike.
• Use cold packs for 15 minutes at a time on painful areas, with a cloth between the pack and your skin.
• Keep moving gently. Short walks and easy, pain-free movement are better than bed rest.
• Sleep is part of healing. Use pillows to support your neck and, if you sleep on your side, a pillow between your knees.
• Take medication only as directed, and tell your provider what you are taking.

The first weeks

• Attend your treatment visits consistently. Early, regular care in the acute phase helps restore motion before stiffness sets in.
• Do your home stretches daily, especially after work or long periods of standing or sitting.
• Avoid heavy lifting, especially lifting while twisting. When you must lift, bend your knees, keep the load close, and turn with your feet instead of your back.
• Keep a simple diary of your pain, headaches, sleep and activities. It helps you and your provider see patterns.

As you improve

• Add stabilization and strengthening exercises as your provider advises, building up gradually.
• Expect occasional flares. If pain rises after a busy day, ease off for a day or two, use cold or heat, and resume your exercises.
• Address recovery factors: supportive shoes or orthotics if your feet roll inward, steady progress toward a healthy weight, regular sleep, and stress management.
• Keep your follow-up and re-examination appointments, even when you feel better.

Setting up your day

• Break long periods of standing or sitting with short movement breaks every 30 to 60 minutes.
• At work, carry loads close to your body and split heavy loads into smaller ones.
• Adjust screens to eye level to avoid looking down for long periods, which strains the neck.
• Plan your heaviest tasks for the times of day you feel best.

Returning to family, work and recreation

• Family life: start with lighter household tasks and share heavier ones. Chores were among the hardest activities for the patient in this case early on.
• Work: talk with your provider about modified duties if your job involves lifting, carrying or long shifts on your feet. Build up hours gradually if possible.
• Recreation: return to exercise and sports in stages, starting with walking, cycling or swimming, and adding running, jumping and contact activities only when you can do the earlier stages without symptoms. If you had a head injury, follow a graded return and stop if symptoms return.

When to seek urgent care

Go to an emergency department or call emergency services if you have any of the following after a collision or head injury:

• A severe or rapidly worsening headache, repeated vomiting, confusion, unusual drowsiness or difficulty waking
• Weakness, numbness or loss of coordination in an arm or leg, slurred speech, or a drooping face
• Loss of bladder or bowel control, or numbness in the groin or inner thighs
• Seizure, fainting, or one pupil larger than the other
• Severe abdominal pain, chest pain or difficulty breathing
• Pain that is constant, severe and unrelieved by any position, or that comes with fever

Ten key takeaways

1. Pedestrians absorb the full force of a collision. With no frame, seat belt, or airbag, the body takes the direct impact and then a second impact with the ground, which explains this patient’s spine, hip, and head injuries.
2. Normal X-rays do not mean no injury. The patient’s hospital X-rays ruled out fracture, but his sprains, strains, and nerve irritation were found on careful examination.
3. One provider with two licenses sees the whole picture. As both a chiropractor and a family nurse practitioner, the lead clinician treated the joints and muscles and also screened the nervous system and managed the medical questions.
4. Holistic and allopathic care work best together. Hands-on care, exercise and attention to body composition and foot mechanics were combined with medical screening, imaging decisions and specialist referral.
5. Multimodal, phased care matches how tissue heals. Several treatments with different purposes, delivered more often early and less often as he improved, followed the guidelines for neck and back pain.
6. Recovery factors deserve attention from day one. High body fat and severe foot pronation did not cause the injuries, but they help explain his flares and shape his long-term plan.
7. Recovery is rarely a straight line. His pain fell from 6 to 1 out of 10, with flares after a good weekend, after work shifts and with weight bearing, each settling within a visit or two.
8. A head strike deserves follow-up even without loss of consciousness. His headaches and brief dizziness were tracked at many visits, and his persistent brief headaches were part of the reason for referral.
9. A full examination at discharge can change the plan. Feeling better is not the same as being fully recovered; a brisk reflex and slight leg weakness at the final visit led to a neurology referral instead of a simple discharge.
10. Good care continues after discharge. His plan includes a home exercise program, supportive care for flares, a specialist evaluation and a formal re-examination before maximum medical improvement is determined.

Glossary of terms

Adjustment (spinal manipulation)

A controlled, quick movement applied to a spinal or limb joint to restore its motion.

Acute, subacute, chronic

Stages of an injury by time: acute is the first weeks, subacute up to about three months, chronic beyond three months.

Body composition analysis

A bioimpedance test estimating fat, muscle and body water, including fluid outside the cells, which can rise with inflammation.

Clonus

Rhythmic muscle beats when a muscle is suddenly stretched; one beat can be normal, sustained beats are abnormal.

Concussion

A mild traumatic brain injury caused by a blow or jolt to the head, with or without loss of consciousness.

Dermatome

The area of skin supplied by a single spinal nerve root.

Facet joints

The small paired joints at the back of each spinal segment that guide its motion.

Hypertonicity

Increased muscle tone or spasm, felt on examination.

Hyperreflexia

A tendon reflex that is brisker than normal.

Ligament

A tough band of connective tissue that joins one bone to another and limits how far a joint can move.

Integrated care

Care in which chiropractic, medical, rehabilitation and wellness services are coordinated by one team around one patient.

Maximum medical improvement

The point at which further meaningful recovery is not expected, determined by a formal examination.

Motion palpation

Feeling the movement of each joint to find segments that are restricted.

Multimodal care

Several treatments with different purposes combined in one coordinated program.

Nerve root

The part of a spinal nerve where it leaves the spinal cord and passes out between two vertebrae; irritation here can cause pain, tingling or weakness along the nerve.

Post-traumatic headache

Headache that begins within a week of a head or neck injury.

Pronation

Inward rolling of the foot and flattening of the arch when standing or walking; severe pronation alters loading of the knees, hips and back.

Range of motion

How far a joint or the spine moves in each direction.

Red flags

Signs that suggest a serious condition needing urgent medical evaluation.

Romberg test

A balance test performed standing with feet together and eyes closed.

Sciatica

Pain along the sciatic nerve, from the low back or buttock down the back of the leg.

Segmental and somatic dysfunction

Restricted or abnormal motion of a spinal or limb joint segment, found on examination and treated by manipulation.

Sensitization

Increased sensitivity of the nervous system after injury, which can make pain linger or flare.

Sprain

An injury to a ligament or joint capsule.

Strain

An injury to a muscle or tendon.

Traction (intersegmental)

A table with rollers that gently moves each spinal segment in turn.

Visceral fat

Fat stored deep in the abdomen around the internal organs; higher levels are linked to inflammation and long-term health risks.

Whiplash

Injury to the neck from sudden acceleration and deceleration of the head, in any direction.

Explore more

References

1. Bussières AE, Stewart G, Al-Zoubi F, et al. The treatment of neck pain-associated disorders and whiplash-associated disorders: a clinical practice guideline. J Manipulative Physiol Ther. 2016;39(8):523-564. doi:10.1016/j.jmpt.2016.08.007
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