Objective To explore the applicability of ultrasound real-time shear wave elastography combined with the American Radiological Society (ACR) thyroid imaging report and data system (TI-RADS) in the diagnosis of benign and malignant thyroid nodules.Methods A total of 277 patients with thyroid nodules admitted to our hospital between December 20, 2016 and December 5, 2018 were selected. All the patients underwent shear wave elastography in the Department of Ultrasound to obtain Young's modulus values and ultrasound images. TI-RADS classification was conducted. According to the biopsy or pathological results, the patients were divided into the benign group and malignant group. The Young’s modulus values and TI-RADS classification difference between benign and malignant thyroid nodules were compared. The Young’s modulus values, TI-RADS classification and joint diagnosis were analyzed. The values of benign and malignant thyroid nodules were determined.Results There were 75 cases of malignant thyroid nodules and 202 cases of benign ones. The elasticity score and SR value of thyroid nodules in the benign group were lower than those in the malignant group (P＜0.05). The correct rate of diagnosis of malignant thyroid nodules according to ACR TI-RADS classification criteria was 88.09% (244/277). ROC analysis showed that the combination of ACR TI-RADS classification and UE had the highest diagnostic efficiency for thyroid cancer. The area under curve (AUC) was 0.922 (95% CI: 0.853-0.991, P=0.000), and the sensitivity and specificity were 97.33% and 99.50% respectively.Conclusions UE combined with ACR TI-RADS classification can improve the diagnostic accuracy of benign and malignant thyroid nodules.