An efficient block matching and spectral shift estimation algorithm for freehand quasi-static ultrasound elastography is described in this paper. The proposed method provides a balance between computational speed and robustness against displacement estimation error and bias; a fundamental aspect of elastography. The new algorithm was tested on an extensive set of simulated 1-D RF ultrasound signals, replicating various strain profiles. Additionally, real 2-D scans were conducted on an ultrasound phantom with prescribed elastic properties; the algorithm output was further validated with a comparison to a finite element model (FEM) of the phantom. Clinical data from a breast cancer study and histology slides were used to demonstrate the in vivo use of the new elastography technique. The algorithm showed a significant computational savings (at least 60 times faster) over existing spectral shift analysis methods. Accurate strain images were produced in as little as 2 s with the scope for further speed enhancements through parallel processing; making real-time implementation a future possibility. Moreover, it demonstrated a robustness toward displacement estimation error when compared with conventional gradient-based techniques, and was able to perform at high strain values (>5%) while showing relative insensitivity to various parameters settings, such as sample rate and block window size; a desirable performance for a practical clinical tool.