Background <p>Breast cancer is a significant global health issue and is a leading cause of female deaths worldwide. Ultrasonography (US) is an adjunct technique for early diagnosis of breast cancer but has low specificity. So, researchers have suggested using US elastography to distinguish between benign and malignant breast lesions, which may lead to a decrease in unnecessary biopsy rates. We aimed to assess the diagnostic performance of strain elastography and if there was an increase in the diagnostic accuracy after adding it to conventional US results in BI-RADS 4 category breast lesions.</p> Results <p>This cross-sectional study was carried out from June 2022 to June 2024 on 240 patients with 240 breast lesions that were diagnosed as BI-RADS 4 category by conventional US. All the cases were examined using conventional US and strain elastography. Out of the 240 lesions, 107 were benign (44.6%) and 133 were malignant (55.4%). There was a significant statistical difference in the mean age of patients with benign breast lesions (37.89 ± 13.42 years) than those with malignant lesions (48.83 ± 13.65 years) (<i>p</i> &lt; 0.001). Lesions’ imaging characteristics detected by conventional US as shape, margin, aspect ratio, vascularity, and calcification all showed significant differences between benign and malignant breast lesions (<i>p</i> &lt; 0.001). The diagnostic accuracy of conventional US alone was 73.3% and increased to 95.3% after combining it with strain elastography. The strain elastography score has a cutoff value of 4 in discriminating malignant from benign lesions (AUC = 0.9).</p> Conclusions <p>Strain elastography provides an added diagnostic value in discriminating malignant breast lesions from benign lesions. The combination of strain elastography with US BI-RADS increases the diagnostic accuracy for the detection of malignant breast lesions which will decrease the need for unnecessary biopsy.</p>