Objectives: To determine the diagnostic performance of elastography strain ratio (SR) for the diagnosis of malignant thyroid nodules taking fine needle aspiration cytology (FNAC) as the gold standard at a tertiary care hospital in Pakistan. Methods: This is a cross-sectional study. A total of 150 cases aged 20-60 years, of either gender, who presented with palpable/suspected malignant thyroid nodules of any size with Thyroid Imaging Reporting and Data System (TIRADS) category 3 or above on ultrasonography were included. These were further evaluated by elastography and ultrasoundguided fine needle aspiration cytology (FNAC). The elastography SR of the nodules was assessed. Final diagnosis was made using ultrasound-guided FNAC. Relevant clinical and demographic data were obtained from patient charts. The diagnostic sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were calculated for elastography using FNAC as a gold standard. Results: The mean age of all patients was 41.8±8.6 years (range: 20-60 years). There were 97 (64.67%) males and 53 (35.33%) females. The majority of patients, 50 (33.33%), belonged to age category of 41 to 50 years. Taking elastography SR of > 2.32 as the cut-off, 69 (46.0%) nodules were positive, and 81 (54.0%) were negative. The FNAC results showed that 72 (48.0%) were positive, and 78 (52.0%) were negative. The diagnostic sensitivity of SR was 92.31%, specificity, 87.50%, positive predictive value, 88.89% and negative predictive value was 91.30%. The overall diagnostic accuracy was estimated to be 87.5%. Conclusion: The results from this study show that elastography and SR are highly valuable in discriminating benign from malignant thyroid nodules. These may serve as an affordable and reliable alternative diagnostic technique, particularly in the developing world.