Early deterioration of reinforced concrete foundations has been often reported in recent years. This process is usually characterized by an extensive mapping cracking process on concrete surfaces that results from several types of Internal Swelling Reaction (ISR). In this paper, a real case study of a tall reinforced concrete building with a severe deterioration process installed in its deep foundations is discussed. Laboratory tests were performed in concrete drilled cores extracted from a deep pile cap block 19 years after the beginning of construction. Tests to assess the compressive strength, the static and the dynamic modulus of elasticity, the gas permeability, and electron microscopy scanning to find out the primary mechanism responsible for the deterioration observed during in situ inspections. Chemical alterations of materials were observed in concrete cores, mainly due to Delayed Ettringite Formation (DEF), which significantly affected the integrity and durability of the structure. Dynamic modulus of elasticity showed to be a better indicator of damage induced by ISR in concrete than compressive strength. Procedures to strengthen the deteriorated elements using prestressing proved to be an efficient strategy to recover the structural integrity of pile caps deteriorated due to expansions due to ISR.