To examine the determinants of confidence in managing musculoskeletal (MSK) disorders among primary care physicians. A self-administered questionnaire was mailed to a stratified (by urban/rural location) random sample of 798 Ontario primary care physicians who were members of the College of Family Physicians of Canada. Two mailings and a reminder postcard were used to increase response. As the main outcome measure, confidence was measured on a 10 point Likert-type scale. The overall response rate was 68.3%. Most respondents were practising in a full time group setting; their average age was 40.3 years. Respondents were significantly more confident in performing a comprehensive cardiovascular examination than a MSK examination. Highest levels of confidence were observed for using nonsteroidal antiinflammatory drugs and managing common MSK disorders. Lower scores were reported for doing a joint injection/aspiration. Rural physicians were more confident than urban physicians in doing a joint injection/aspiration and monitoring patients who were taking disease modifying agents. Previous continuing medical education (CME) was significantly (p < 0.01) related to all confidence outcomes using multiple regression analysis. For many outcomes, men reported higher confidence scores than women after adjustment for various demographic characteristics. CME may be the most important and modifiable variable to improve physician management of MSK disorders.