CCFP priority topic 57 of 105
Joint Disorder on the CCFP exam
10 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 10 key features for Joint Disorder. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 10
Benign or dangerous
Separate harmless joint pain from infection or a bone tumour, using history and prompt tests.
CFPC skill Selectivity, clinical reasoningPhase Hypothesis generation, history, investigation, diagnosisSources Choosing Wisely Canada
On the exam
A man with past toe attacks has a hot, swollen knee for 2 days. Expect a short menu (pick several from a list).
Pick the questions and the first test.
Common mistakes
Calling it gout because of the toe attacks and the nightly beer, or ordering an X-ray and waiting. Neither excludes infection. Only joint fluid does.
Approach
- Ask about fever, chills, a skin break or injection near the joint, joint surgery, and new sexual partners.
- Aspirate a hot, swollen joint the same day. Send the fluid for cell count, Gram stain, culture and crystals.
- Do not wait on an X-ray. Early in an infection it looks normal and cannot tell infection from crystals.
- A fast response to a nonsteroidal anti-inflammatory drug (NSAID) proves nothing. Infected joints settle on it too.
- Ask about pain at night, weight loss and night sweats. In a child or teen, these or a swollen joint call for an X-ray.
Key feature 2 of 10
Name the pattern
When the story, exam and tests point to one rheumatic disease, name it.
CFPC skill Clinical reasoningPhase DiagnosisSources Choosing Wisely Canada, Health Canada
On the exam
A breastfeeding mother of 31 has 8 weeks of hand pain and swollen knuckles. Expect one best answer.
Pick the most likely diagnosis.
Common mistakes
Blaming lifting the baby, her mother's knobbly fingers, or tired nights. Soft knuckle swelling with positive anti-cyclic citrullinated peptide (anti-CCP) antibodies points to rheumatoid arthritis.
Approach
- Map the joints: one or many, large or small, one side or both.
- Look for soft, warm swelling and long morning stiffness. Hard bony knobs at the finger ends point to osteoarthritis instead.
- Order rheumatoid factor and anti-CCP only with swollen joints or a suspicious pattern. Without arthritis, many people who test positive do not develop rheumatoid arthritis within 2 years.
- Diagnose gout by crystals in joint fluid. A high urate with no attacks is generally not a reason to treat.
- Parvovirus can mimic early rheumatoid arthritis in adults around young children. It usually settles within weeks.
- Fibromyalgia means widespread pain with poor sleep and tiredness, but no swollen joints. Swollen joints point to another cause. Fibromyalgia does not explain them.
| Pattern | Think of | Clue |
|---|---|---|
| One hot joint | Infection, gout or pseudogout | Joint fluid decides |
| Small joints of both hands | Rheumatoid arthritis | Long morning stiffness, soft knuckle swelling |
| Finger-end joints, older adult | Osteoarthritis | Hard bony swelling, short stiffness |
| A few large joints, with back, eye or gut symptoms | Spondyloarthritis (inflammatory arthritis of the spine) or reactive arthritis | Inflammatory back pain, recent infection |
| Pain everywhere, no swelling | Fibromyalgia | Normal joint exam, poor sleep |
Key feature 3 of 10
Infection in one joint
When one joint is inflamed, exclude infection, including one caught through sex.
CFPC skill Selectivity, clinical reasoningPhase Diagnosis, hypothesis generationSources Choosing Wisely Canada
On the exam
A man of 67 has a warm, swollen wrist for 3 days after moving knee pain. Expect a short menu (pick several from a list).
Pick the questions and tests for today.
Common mistakes
Chasing a family history of rheumatoid arthritis with serology, or ordering HLA-B27 for reactive arthritis. A warm single joint after recent sex needs fluid, cultures and swabs.
Approach
- Treat a new warm single joint as infected until joint fluid says otherwise.
- Ask about new or several sexual partners, condom use, and genital, throat or rectal symptoms. Ask at any age.
- Disseminated gonorrhea (spread through the blood) can bring moving joint pain, tendon pain at the wrist or hand, and skin spots.
- Send joint fluid and blood cultures. Test for gonorrhea and chlamydia at every exposed site: urine or genital, throat and rectum.
- Gonorrhea is often carried without symptoms. Arrange partner notification and testing with public health.
- HLA-B27, a gene marker, is only for suspected spondyloarthritis. Lyme serology needs tick exposure or life in an endemic area, plus arthritis that fits.
Key feature 4 of 10
Pain from elsewhere
When a limb or joint hurts, think of pain coming from the hip, heart, organs or nerves.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Choosing Wisely Canada
On the exam
A heavy 12-year-old boy limps with knee pain and a normal knee exam. Expect one best answer for the next test.
Pick the test that finds the cause.
Common mistakes
Imaging the sore knee and calling it normal, or calling it growing pains. A slipped hip growth plate sends pain to the knee.
Approach
- Examine the joint above and below. Knee pain in a child can come from the hip.
- A heavy preteen or teen with a limp and knee pain: think of a slipped capital femoral epiphysis (the hip growth plate sliding). X-ray both hips.
- In a child, get plain X-rays before any magnetic resonance imaging (MRI) or computed tomography (CT) scan.
- Shoulder, arm or jaw pain that comes with effort and eases with rest: think of angina. Get an electrocardiogram (ECG).
- Burning, tingling or numbness along a nerve points to nerve pain, often from the neck or back.
- Shoulder-tip pain can come from the gallbladder or diaphragm. Examine the belly.
Key feature 5 of 10
Sprains
Diagnose a torn or stretched ligament by examination, without ordering imaging.
CFPC skill Clinical reasoning, procedure skillsPhase Physical, diagnosisSources Choosing Wisely Canada
On the exam
A teenager rolled an ankle playing soccer and can still walk. Expect a short menu (pick several from a list).
Pick the exam findings and the plan.
Common mistakes
Ordering an X-ray or ultrasound for a typical sprain, or putting it in a rigid cast. Skipping the Ottawa Ankle Rules and missing a bony injury is wrong too.
Approach
- Take the mechanism: a twist, a pop, how fast it swelled, and whether the patient could bear weight.
- Test the ligament directly. Knee: the Lachman test for the anterior cruciate, and side stress for the collaterals. Ankle: tenderness over the ligaments and the anterior drawer test.
- Apply the Ottawa Ankle Rules. If negative, no X-ray. They apply after blunt injury within 10 days, in alert, cooperative patients over 2 with normal feeling.
- No ultrasound for a typical sprain or Achilles tear when history and exam make the diagnosis.
- Treat an ankle sprain with a functional brace and early movement, not rigid immobilization.
- Skip MRI for a degenerative meniscus tear. Keep it for locking or failed conservative care.
| Injury | Diagnose with | Imaging |
|---|---|---|
| Ankle sprain | Mechanism, ligament tenderness, Ottawa Ankle Rules | X-ray only if the rules are positive |
| Achilles tear | History and exam | No ultrasound when the exam makes the diagnosis |
| Knee ligament tear | Lachman test, side stress tests | No X-ray to diagnose the ligament |
| Degenerative meniscus tear | Older adult, slow onset, no locking | MRI only for locking or failed conservative care |
Key feature 6 of 10
Systemic disease
Remember that whole-body diseases, such as lupus, vasculitis or bowel disease, can cause joint pain.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Choosing Wisely Canada
On the exam
A woman of 26 has painful hands, a rash and mouth sores. Expect a short menu (pick several from a list).
Pick the questions that find a systemic cause.
Common mistakes
Stopping at the joints and missing her rash, ulcers or blood in the urine. Or ordering an antinuclear antibody (ANA) for a hot single joint: it changes nothing today.
Approach
- Ask about rash, mouth sores, hair loss, and fingers turning white or blue in the cold (Raynaud).
- Ask about dry eyes and mouth, nose bleeding or crusting, coughing blood, and bloody diarrhea.
- Check blood pressure and test the urine for blood and protein. Kidney involvement makes it urgent.
- Order ANA only with signs of lupus or another systemic autoimmune disease. Up to 20% of healthy people test positive.
- Granulomatosis with polyangiitis, once called Wegener, hits the nose, lungs and kidneys. Ulcerative colitis and Crohn disease can bring joint and back pain.
- A single hot joint is still infection first. Systemic questions come after the fluid.
Key feature 7 of 10
Drugs and other illness
Ask about other illnesses before treating a rheumatic disease, and pick drugs that suit them.
CFPC skill Clinical reasoningPhase History, treatmentSources Choosing Wisely Canada, Health Canada
On the exam
A man has his third gout flare this year, with kidney disease, ramipril, a diuretic and a past bleeding ulcer. Expect one best answer.
Pick the safest plan.
Common mistakes
An NSAID because it worked before, or a cyclo-oxygenase-2 (COX-2) inhibitor as the gentle choice. Starting allopurinol at 300 mg without flare cover is wrong too.
Approach
- Before any drug, ask about kidney disease, ulcers or bleeding, heart failure, diabetes, alcohol, current medicines and pregnancy plans.
- No NSAID, including a COX-2 inhibitor, with high blood pressure, heart failure or chronic kidney disease. They raise blood pressure, hold fluid and worsen kidney function.
- A past bleeding ulcer is another reason to avoid an NSAID.
- Start allopurinol at 100 to 200 mg a day. Raise it by 100 mg each week until the urate reaches target. Use lower doses in kidney disease.
- Give colchicine to prevent flares when allopurinol starts.
- A flare on allopurinol: keep the same dose and treat the flare.
- Stop allopurinol at the first rash. Kidney disease plus a diuretic, above all a thiazide, raises the risk of severe reactions.
- Methotrexate is contraindicated in severe kidney disease, alcohol use disorder and chronic liver disease.
| Other illness | Avoid or adjust | Why |
|---|---|---|
| High blood pressure, heart failure or chronic kidney disease | NSAIDs, COX-2 inhibitors included | Raise blood pressure, hold fluid, worsen kidney function |
| Kidney disease on a thiazide | Allopurinol: start low, watch for rash | Higher risk of severe skin and hypersensitivity reactions |
| Severe kidney disease, alcohol use disorder or liver disease | Methotrexate | Contraindicated |
| Peptic ulcer disease | Methotrexate needs extreme caution | Gut toxicity: stop it for diarrhea or mouth ulcers |
Key feature 8 of 10
Complications
In a patient with known rheumatic disease, look for problems the disease or its drugs cause.
CFPC skill Clinical reasoningPhase Hypothesis generationSources Choosing Wisely Canada, Health Canada
On the exam
A man with spondyloarthritis (inflammatory arthritis of the spine) has a painful red eye. Expect a short menu (pick several from a list).
Pick the questions and the next step.
Common mistakes
Calling it conjunctivitis and giving drops. In spondyloarthritis, a painful red eye with light sensitivity is iritis until an eye exam says otherwise.
Approach
- Ask about eye pain, redness, blurred vision and light sensitivity at each visit.
- A painful red eye in spondyloarthritis needs a same-day eye exam for iritis (inflammation inside the eye).
- Children with juvenile idiopathic arthritis need regular eye checks. A positive ANA marks a higher risk of iritis.
- Lupus: check blood pressure and urine at visits for kidney involvement.
- On methotrexate, a dry cough, fever or breathlessness can mean drug lung disease or infection. Hold the drug and investigate.
- Methotrexate can drop blood counts. Stop it at once if counts fall sharply.
Key feature 9 of 10
Pain and daily life
Ask what the pain stops the patient doing, give enough pain relief, and arrange practical help.
CFPC skill Patient-centred approach, clinical reasoningPhase History, treatment, referralSources Choosing Wisely Canada
On the exam
A man of 67 on ramipril and a diuretic still has knee pain on acetaminophen. Expect one best answer.
Pick the next pain treatment.
Common mistakes
Adding codeine, which brings constipation, confusion and falls at his age. Or an NSAID or COX-2 inhibitor alongside his two blood pressure drugs.
Approach
- Ask what the pain stops: sleep, work, stairs, dressing, driving, caring for others.
- Still in pain on acetaminophen: give it regularly at full dose, add exercise and physiotherapy, and offer a cane before any new drug.
- Make physical activity the base of care for osteoarthritis.
- Use regular, full doses of acetaminophen before you call it a failure.
- Do not start long-term opioids for chronic joint pain. In hip and knee osteoarthritis they did no better than non-opioids for function over 12 months.
- Offer a cane in the hand opposite the sore hip or knee, splints or braces, and physiotherapy or occupational therapy.
- Link the patient to community supports: arthritis education, exercise programs, home care.
Key feature 10 of 10
Early rheumatoid arthritis drugs
In rheumatoid arthritis, begin disease-modifying drugs without delay.
CFPC skill Clinical reasoningPhase TreatmentSources Health Canada
On the exam
A breastfeeding mother of 31 has new rheumatoid arthritis. Expect a short menu (pick several from a list).
Pick the steps for this visit.
Common mistakes
Waiting until weaning, or giving prednisone alone, leaves her joints untreated for months. Methotrexate is the reflex pick, but it does not suit breastfeeding.
Approach
- Start a disease-modifying drug soon after diagnosis. Joint damage can begin within months.
- Refer to rheumatology early, and do not let the wait delay treatment.
- Prednisone eases symptoms fast but does not replace a disease-modifying drug. Use it only as a short bridge.
- Methotrexate is contraindicated in pregnancy and while breastfeeding. Exclude pregnancy before starting it.
- Avoid pregnancy while either partner takes methotrexate. Reported waits after stopping range from 3 months to a year.
- Methotrexate is taken once a week. Taking the weekly dose daily has caused deaths, especially in older patients.
- Before methotrexate: blood count, liver enzymes, kidney function, hepatitis B and C tests, and a chest X-ray.
Flashcards
Answer it first, then check.
KF 1A man with past gout has a hot, swollen knee for 2 days. First test?
Aspirate the knee today. Send fluid for cell count, Gram stain, culture and crystals.
KF 3A warm single wrist after recent sex. Which tests come first?
Joint fluid, blood cultures, and gonorrhea and chlamydia tests from every exposed site.
KF 5The Ottawa Ankle Rules are negative after a rolled ankle. Do you order an X-ray?
No. The rules hold for alert patients over 2, injured within the last 10 days. Source: Choosing Wisely Canada
KF 6Should a hot single knee get an antinuclear antibody (ANA) test?
No. Order ANA only with signs of lupus or similar disease. Up to 20% of healthy people test positive. Source: Choosing Wisely Canada
KF 7Gout flare with chronic kidney disease and high blood pressure. Is naproxen safe?
No. NSAIDs, COX-2 inhibitors included, raise blood pressure, hold fluid and worsen kidney function. Source: Choosing Wisely Canada
KF 7You start allopurinol for repeated gout. What dose, and what else?
100 to 200 mg a day, raised by 100 mg weekly, with colchicine to prevent flares. Source: Health Canada
KF 8On methotrexate, a new dry cough and fever. What do you think of?
Methotrexate lung disease or an infection such as pneumonia. Hold the drug and investigate. Source: Health Canada
KF 10How often is methotrexate taken for rheumatoid arthritis?
Once a week. Taking the weekly dose every day has caused fatal toxicity. Source: Health Canada
FAQ
Does a normal uric acid rule out gout?
No. Urate can be normal during a flare and high without one. Crystals in joint fluid make the diagnosis. Use the urate level to guide the allopurinol dose.
Why is a quick response to an anti-inflammatory not reassuring?
Because NSAIDs calm infected joints too. Pain and swelling can ease while bacteria damage the joint. A good response cannot exclude a septic joint; only joint fluid can.
When does a sprained ankle need an X-ray?
When the Ottawa Ankle Rules are positive. A negative result in an alert patient injured within 10 days means no X-ray. Diagnose the ligament injury itself by examination.
Which Canadian guideline does this topic follow?
No single Canadian guideline covers it. Choosing Wisely Canada lists tests to skip, and Health Canada product monographs set drug doses and limits. The rest is core clinical reasoning.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada