Background: Thyroid nodules are common clinical findings, and differentiating benign from malignant lesions is essential for appropriate management. Conventional ultrasonography (USG) is widely used, while strain elastography provides additional information regarding tissue stiffness. Aim: To compare the diagnostic performance of conventional USG, strain elastography, and their combined approach in differentiating benign from malignant thyroid nodules. Materials and Methods: This observational, cross-sectional study included 66 patients with thyroid nodules evaluated at a tertiary care hospital. Conventional USG assessed nodule morphology, echogenicity, margins, shape, echogenic foci, and vascularity, with classification according to ACR TI-RADS. Strain elastography was performed using Rago elasticity scores and strain-ratio measurements. Fine-needle aspiration cytology, supplemented by histopathology where available, served as the reference standard. Diagnostic performance was assessed using sensitivity, specificity, predictive values, accuracy, and receiver operating characteristic analysis. Results: Of the 66 patients, 54 (81.8%) had benign nodules and 12 (18.2%) had malignant nodules. Suspicious sonographic features and higher ACR TI-RADS categories were significantly associated with malignancy (p < 0.001). The mean strain ratio was significantly higher in malignant than benign nodules (4.92 ± 1.05 versus 1.82 ± 0.87; p < 0.001). The strain-ratio cut-off of 2.80 yielded an area under the curve of 0.982, with 100% sensitivity and 88.89% specificity. Diagnostic accuracy was 80.30% for USG, 89.39% for elastography, and 92.42% for the combined approach. Conclusion: Strain elastography improved diagnostic performance compared with conventional USG alone. Their combined assessment demonstrated the highest observed accuracy and specificity, suggesting complementary value in thyroid nodule characterization. Larger prospective studies are required to validate these findi