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Background: Axillary ultrasonography is a non-invasive and sensitive method used in the evaluation of breast cancer. We sought to evaluate the value of axillary ultrasonography in the nodal staging of breast cancer patients with axillary lymph node metastases. Methods: From a retrospective database, we reviewed the electronic medical records of breast cancer patients with axillary lymph node metastases who underwent curative surgery between 2003 and 2020. We collected the relevant clinicopathological data and ultrasonographic images. We performed a binary logistic regression analysis to evaluate the factors associated with a high nodal stage. Results: A total of 563 patients were included. Total mastectomy, larger tumor size, abnormal axillary ultrasonography, high histologic grade, lymphatic invasion, hormonal receptor negativity, and HER2 receptor positivity were associated with a pN2 or higher nodal stage. A receiver-operator curve analysis revealed that two or more abnormal lymph nodes seen on axillary ultrasonography identified a high nodal stage with a sensitivity of 62.2% and a specificity of 85.3%. Multivariate analysis revealed that patient age less than 50, lymphatic invasion, two or more abnormal lymph nodes, and hilar effacement were independent predictive factors for the high nodal stage. Conclusion: In patients with two or more abnormal lymph nodes on axillary ultrasonography, upfront axillary lymph node dissection or neoadjuvant chemotherapy is preferred. Our findings highlight the importance of axillary ultrasonography in the nodal staging of breast cancer.