Objective To evaluate the value of ultrasound elastography (UE) in the differential diagnosis of benign and malignant thyroid nodules in Hashimoto’s thyroiditis (HT). Methods A total of 83 patients with thyroid nodules admitted to Ruzhou First People’s Hospital due to HT from January 2022 to May 2024 were selected, and all of them underwent conventional ultrasound and UE examination after admission. The results of puncture pathological biopsy were used as the gold standard to analyze conventional ultrasound findings, UE evaluation results, and the diagnostic value of thyroid nodules under HT background. Results Among 140 thyroid nodules in 83 patients, there are 48 benign nodules and 92 malignant nodules. The irregular shape, blurred boundary, low echo, microcalcification, RI ≥ 0.07 and the proportion of Ⅱ - Ⅲ blood flow signals in malignant nodules were higher than those in benign nodules (P ＜ 0.05). The results of UE evaluation showed that the elastic score, strain rate ratio and nodule diameter of malignant nodules were larger than those of benign nodules under HT background (P ＜ 0.05). Among 140 thyroid nodules, 45 benign and 95 malignant nodules were diagnosed by conventional ultrasound, and 36 benign and 86 malignant ones jointly by gold standard. UE diagnosed 47 benign nodules and 93 malignant nodules, jointly diagnosed 45 benign nodules and 90 malignant nodules, which were inconsistent. ROC curve analysis showed that the diagnostic sensitivity (96.74%) and specificity (89.58%) of UE were higher than those of conventional ultrasound (89.13% and 75.00% respectively). Conclusions UE examination is of high diagnostic value in diagnosing the lesion properties of thyroid nodules in the background of HT by means of lesion elasticity score and strain rate.