Objectives This study aimed to compare 2 types of strain ratios (SRs) in thyroid nodules. Two reference points were used: the sternocleidomastoid (SCM) muscle and the thyroid parenchyma. Methods A total of 101 nodules in 83 patients were prospectively enrolled in the study. For the semiquantitative analysis, 2 types of SRs were used: SR1, the ratio of the SCM muscle strain to the thyroid nodule strain; and SR2, the ratio of the surrounding normal thyroid tissue strain to the thyroid nodule strain. For each nodule, the SR1 and SR2 elastographic values were calculated, and their averages were compared. Results Eighty-one (80.2%) of 101 thyroid nodules were benign, and 20 (19.8%) were malignant. In both benign and malignant histopathologic types, the SR1 averages were significantly higher than the SR2 averages (P = .001; P < .001, respectively). Both the SR1 and SR2 values were found to be significantly successful in differentiating benign from malignant histopathologic types (P < .001 for both). The areas under the curve were then compared for the methods, and the difference was found to be statistically significant (P = .046). The diagnostic accuracy of the SR1 was superior to that of the SR2. Conclusions The SR1 and SR2 are effective adjunctive diagnostic tools for identifying malignant thyroid nodules. Using the SCM muscle as a reference point instead of thyroid tissue may be a more valuable way to measure SRs.