I swear by quilting without a hoop. It's possible to get much smaller stitches this way.
The quilt sandwich has to be well-basted, more so than quilting in a hoop. I layer the backing, batting and top, but don't stretch any of them. Since I'm rather lazy, I put pins in every three inches-ish to stabilize the piece and put even more in the area where I'll be starting. As I remove safety pins in the area I'm working on, I move them over to the place I'm going next.There is no tension on the quilt sandwich as I'm working. I don't pull it taut or stretch it in any way.
I hold the quilt in my left hand between my thumb and palm. Not the middle of my palm - that would be uncomfortable -- but the area below my index finger (the finger closest to the thumb). This is what it looks like from the top of the quilt:
And when I get even closer to the edge you can see it that much better because the quilt isn't covering my hand:
And this is what it looks like from underneath the quilt:
My left hand doesn't do much during the quilting other than hold the quilt steady and up where I need it. However the middle finger *is* important. First it gets "stabbed" by the needle. After the needle makes contact, my finger then acts to push that needle back up. (Not by the pointy bit of the needle, but the shaft very close to the point.)
My right hand does the bulk of the work. I use a thimble on my middle finger to push the needle. My right thumb is crucial. As I rock my hand, my thumb works to first help the needle go down and and then come back up. For the down motion, my thumb is behind the point of the needle, helping to push the shaft down.
For coming back up, the thumb moves forward to help the needle back up. The middle left finger is pushing up on the shaft of the needle, the right thumb is pressing the quilt sandwich down and back against the tip of the needle to make the stitch.
I take several stitches onto the needle and then pull through.
The one drawback to quilting like this is that markings tend to get rubbed off, at least when I do them. So I never mark my quilting designs in advance, always just do a bitty bit as needed. Or, as in the case with my free-hand fans, I quilt without marking anything at all.
I swear by my "Thergonomic Hand-Aids" - they really do work. I don't have nearly as much pain in my hands and wrists as I used to get. Just make sure you buy the kind that have a wide wrist band. I throw them in the wash with my usual laundry every week and into the dryer as well (even though the instructions say not to) because that helps get them tight again.