In smooth muscle, alternative mRNA splicing of a single gene produces four myosin heavy chain (SMMHC) isoforms. Two of these isoforms differ by the presence [(+)insert] or absence [(-)insert] of a seven amino acid insert in the motor domain. This insert enhances the kinetic properties of myosin at the molecular level but its exact role at the cell and tissue levels still has to be elucidated. This review focuses on the expression and biological functions of the (+)insert isoform. Current knowledge is summarized regarding its tissue distribution in animals and humans. Studies at the molecular, cellular and tissue levels that aimed at understanding the contribution of this isoform to smooth muscle mechanical function are presented with a particular focus on velocity of shortening. In addition, the altered expression of the (+)insert isoform in diseases and models of diseases and the compensatory mechanisms that occur when the (+)insert is knocked out are discussed. The need for additional studies on the relationship of this isoform to contractile performance and how expression of this isoform is regulated are also considered.