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Floor Reaction AFO, front view

A Ground (Floor) Reaction Ankle Foot Orthosis (GRAFO or FRAFO) is a type of custom fabricated, molded plastic, AFO capable of triplanar control of the foot/ankle complex. Generally formed from polypropylene, there are several variations on the GRAFO but all include an anterior shell which captures the tibia proximally. [1]


Like many AFO designs, the GRAFO improves frontal plane stability and is capable of limiting transverse motions at the ankle/foot complex. Varying amounts of sagittal motion control can also be achieved depending on the thickness of plastic used and the addition of struts or, conversely, hinges. Depending on the treatment plan, the GRAFO can maintain affected joints in proper alignment, accentuate knee extension at midstance, and compensate for weakness in the triceps surae. The anterior shell section redistributes ground reaction and extension forces closer to the knee than other AFO designs and allows the brace more leverage than more distal AFO designs.[2]

Indications [3] [4][]

  • Adult Acquired Flatfoot
  • Posterior Tibial Tendon Dysfunction (PTTD)
  • Achilles Tendonitis
  • Osteoarthritis
  • Spina Bifida
  • Cerebral Palsy
  • Brain injuries
  • Spinal cord injuries
  • Post-polio paralysis

Popular Variations[]

There are several common designs of GRAFO, which are:

  1. One piece: enclosing the back of the lower calf, the shin, and the bottom of the foot. [5]
  2. Two piece: same as the one piece but with a removable anterior shell. [6]
  3. Rear opening: encloses the front of the leg and top of the foot. [7]

Aside from the common GRAFO designs, research and development performed by practicing orthotists has led to some popular new designs.

Helios E/I and Helios Excel [8]

Researched and developed by Mitchell Warner, CPO, of Ortho Rehab Designs, the Helios orthosis is custom made to provide standing stability, limb correction, increased walking speed, and can enable running in patients who have the ability by providing proper leg/ankle/foot alignment coupled with spring in the brace to help decrease fatigue. The Helios design is recommended for foot/ankle weakness, varus, valgus, balance instability, and footdrop regardless of the underlying diagnosis that caused the lower limb weakness.

Composite AFO Design by Dynamic Bracing Solutions [9][]

Developed by Marmaduke Loke and Jean-Paul Nielsen, the key to this design lies in the material composition and two flexible struts. This flexibility provides two important elements: a dynamic response to propel the limb forward and a progressive resisting force near the knee. Dynamic Bracing Solutions recommends this design for a wide range of skeletal deviations, functional deficits, and neuromuscular disorders.

Texas TURBO AFO by Advanced Orthopedic Designs [10][]

Developed by Kevin Matthews and his associates, the key to this design is the long polypropylene strut that runs from the medial arch proximally and across the tibia before running distally and terminating near the lateral malleoli. In contrast to the Composite AFO Design, this strut provides maximum rigidity and therefore can limit the majority of ankle/foot triplanar motions. For this reason, Advanced Orthopedic Designs recommends the Texas TURBO AFO for PTTD, Achilles Tendonitis, Arthritis, Plantar Fasciitis, and any other diagnosis where ankle/foot motion is contraindicated.

HCPCS Coding[]

  • L1945 - Ankle Foot Orthosis, Plastic, Rigid Anterior Tibial Section (Floor Reaction), Custom-Fabricated [11]